Block

MFN- 006
Public Nutrition
Indira Gandhi
National Open University
School of Continuing Education
UNIT 1
Concept of Public Nutrition 7
UNIT 2
Public Nutrition: Multidisciplinary Concept 26
UNIT 3
Nutritional Problems-I 44
UNIT 4
Nutritional Problems -II 80
UNIT 5
Health Economics and Economics of Malnutrition 96
UNIT 6
Population Dynamics 119
UNIT 7
Assessment of Nutritional Status in Community Settings-I 138
UNIT 8
Assessment of Nutritional Status in Community Settings -II 161
UNIT 9
Nutrition Monitoring and Nutrition Surveillance 187
UNIT 10
Nutrition Policy and Programmes 203
UNIT 11
Review of National Nutrition Programmes 246
UNIT 12
Strategies to Combat Public Nutrition Problems -I 268
UNIT 13
Strategies to Combat Public Nutrition Problems -II 291
UNIT 14
Programme Management and Administration 316
UNIT 15
Conceptualization and the Process of Nutrition Education 349
UNIT 16
Nutrition Education Communication Programmes:
Formulation 371
UNIT 17
Nutrition Education Communication Programmes:
Implementation 388
UNIT 18
Nutrition Education Programme: Evaluation 408
Prof. H.P.Dikshit Prof. S.C.Garg
Vice-Chancellor Pro.Vice-Chancellor
M.Sc. (DFSM) Expert Committee

Prof. Tara Gopaldas Dr. Shobha Udipi Dr. Indira Chakraborthy
Tara Consultancy Services Rtd. Professor, Department of All Indian Institute of Hygiene and
Bangalore-560093 Foods and Nutrition Public Health
SNDT University, 110, Chittaranjan Avenue
Mumbai. Kolkatta
Dr. Umesh Kapil

Dr. Kumud Khanna Dr. Sushma Sharma Human Nutrition Unit
Former Director Rtd. Associate Professor All Indian Institute of Medical
Institute of Home Economics, Department of Foods and Sciences
F-4, Hauz Khas Enclave Nutrition, Lady Irwin College, New Delhi
New Delhi New Delhi
Dr. Ulvir V Mani
Dr. Mary Mammen Dr. Parvathi Eashwaran Professor, Department of Food and
Christian Medical College and Department of Foood Service Nutrition
Hospital Management Avinashilingam College of Home Science
Udam Seudder Road Institute of Home Science M.S.University
Post Box No.3 and Higher Education for Women Vadodara
Vellore Deemed University, Coimbatore
Dr. (Mrs.) K. Puri
Dr. Rekha Sharma Dr. (Mrs.) Molly Joshi Former Professor
Ex. Chief Dietitian Ex. Chief Dietitian Foods and Nutrition Department
All India Institute of Medical Department of Dietetics Punjab Agricultural
Sciences CMC Hospital University, Ludhiana
New Delhi Ludhiana, Punjab
Prof. Deeksha Kapur (Convenor)
Dr. Shikha Khanna Prof. Annu J Thomas Discipline of Nutritional Sciences
Ex. Chief Dietitian School of Continuing Education School of Continuing Education,
Ram Manohar Lohia Hospital, IGNOU, New Delhi IGNOU, New Delhi
New Delhi
M.Sc. (DFSM) Programme Coordinator

Prof. Deeksha Kapur
Discipline of Nutritional Sciences
IGNOU, New Delhi
MFN-006 Course Coordinator - Prof. Deeksha Kapur
MFN-006 Course Design and Preparation Team

Content Contributors
Mrs. Arvind Wadhwa (Unit 1) Prof. Deeksha Kapur (Units 10,12) Unit Transformation
Lady Irwin College, New Delhi Discipline of Nutritional Sciences Prof. Deeksha Kapur
Dr. Ravinder Chadha (Unit 2) School of Continuing Education Ms. Neelam Bhatnagar
Lady Irwin College Indira Gandhi National Open University
(Junior Consultant)
New Delhi New Delhi
IGNOU, New Delhi
Dr. K. Vijayaraghavan (Units 3,4,7,8,9) Dr. Umesh Kapil (Unit 11)
ICMR Emeritus Human Nutrition Unit
Medical Scientist, National Institute All Indian Institute of Medical Sciences
of Nutrition (NIN) New Delhi
Hyderabad
Prof. Tara Gopaldas (Unit 13)
Dr. C. S. Pandav (Unit 5) Tara Consultancy Services, Bangalore
Centre for Community Medicine Dr. Meenakshi Mehan (Unit 14)
All India Institute of Medical Sciences Department of Foods and Nutrition
New Delhi M.S.University, Baroda
Dr. Sushma Sharma (Unit 6) Dr. Shubhada Kanani (Unit 15-18)

Lady irwin college Department of Foods and Nutrition
M.S. University, Vadodra
New Delhi
MFN-006 Course Editor(s)
Dr. Sushma Sharma Prof. Deeksha Kapur
Department of Foods and Nutrition Discipline of Nutritional Sciences
Lady Irwin College School of Continuing Education
New Delhi IGNOU, New Delhi
MFN-006 Course Revision Team

Prof. Deeksha Kapur Dr. Himanshi Rathore
Discipline of Nutritional Sciences Consultant
School of Continuing Education School of Continuing Education
IGNOU, New Delhi IGNOU, New Delhi
PRINT PRODUCTION
Mr. Arvind Kumar
Assistant Registrar (Publication)
IGNOU, New Delhi
July, 2019 (Revised)

 Indira Gandhi National Open University, 2006
ISBN-81-266-2300-4
All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other
means, without permission in writing from the Indira Gandhi National Open University.
Further information, about the Indira Gandhi National Open University courses may be obtained from
the University’s office at Maidan Garhi, New Delhi-110 068.
Printed and published on behalf of the Indira Gandhi National Open University by Director, School
of Continuing Education.
Laser Typeset by : Rajshree Computers, V-166A, Bhagwati Vihar, (Near Sector 2, Dwarka), Uttam Nagar,
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Printed at :
Public Nutrition
INTRODUCTION
Public nutrition focuses on the promotion of good health through nutrition and he
primary prevention of nutrition related illness in the population. It strives to improve
or maintain optimum nutritional health of the whole population and high risk or
vulnerable’ groups within the population. It emphasizes health promotion and disease
prevention but may include therapeutic and rehabilitative services when these needs
are not adequately addressed by other parts of the health care system. Public nutrition
uses multiple, coordinated strategies to reach and influence the community and
organizations Id individuals that make up the community.
The present course, Public Nutrition (MFN-006), is therefore, so designed so as
to focus on the promotion of good health through nutrition and the primary prevention
of nutrition related illness in the population. It deals with nutritional epidemiology
- studies relating nutrition’ to health or disease risk - including monitoring, surveillance
and evaluation, dietary guidelines for the population, evaluation of effectiveness of
intervention studies aimed at improving health, role of nutrition in high-risk and
vulnerable groups, population-based research related to primary prevention of illness,
nutrition education for behavioural change, public policies relevant to nutrition etc.
There are 18 units in this course.
Unit 1 introduces the concept of nutrition and health, with a deeper insight into
the scope and the likely future projections of public nutrition. A broad introduction
and understanding of the health care system, its different levels and health care
delivery system is presented I in this unit. The role of public nutritionist in the delivery
of health care services is also elaborated in this unit.
Unit 2 explains the multi-disciplinary concept of public nutrition,dealing with causative
factors underlying public nutrition problems and how to solve these. Further the unit
deals with the role of agriculture in influencing health and nutritional status of the
people. How does distribution and storage of food influences food availability and
food consumption patterns? What is the role of science and technology in improving
food supply? These are a few issues highlighted in this unit. Lastly, it focuses on
the concept of food and nutrition security, its determinants and India’s food security
system.
Nutritional problems are widely prevalent in our country, especially among poor
families. All of us require adequate nutrition to be able to lead a healthy life, as
any lack or imbalance could cause ill health, leading to nutritional disorders and
even death. Unit 3 focuses on a few important nutritional problems affecting our
population. These include PEM, vitamin A, iron, iodine and zinc deficiency disorders.
The causes, consequences, prevention, control and treatment of these public health
problems are described in this unit.
Unit 4 further probes into the other nutritional problems in India and other developing
countries caused due to poor diet or other environmental conditions. These problems
include deficiencies caused due to lack of vitamin B-complex (like thiamine, riboflavin,
niacin, folate and B12), as well as, vitamin C and D. The unit also focuses on disease
such as fluorosis and lathyrism- ,disease caused due to excessive fluoride content
in diet and due to presence of toxic components present in food items, respectively.
The economics of health and nutrition, in terms of food security, food production
and food pricing is presented in Unit 5. The economic consequences of malnutrition
are described next, focusing on causes, consequences, indicators of nutrition and
interventions in nutrition.
The concept of demography, demographic transition and demographic cycle is dealt
in Unit 6. What are the trends in population growth? What changes are taking
4 place in structure and composition of human population? These are a few issues
dealt in this unit. The unit also focuses on the implications of vital statistics such Concept of Public
as infant mortality rate (IMR), maternal mortality rate (MMR), under 5 mortality Nutrition
rate (U5MR) , fertility rate, sex ratio, life expectancy. Lastly, the unit deals with
the population policy and relationship between fertility, nutrition and quality of life.
Next, Unit 7, focuses on the methods (both direct and indirect) in assessment of
nutritional status of a community. The concept and uses of nutritional anthropometry
i introduced in this unit. What are the common anthropometric measurements that
are used in the community setting? What are the different methods of classification
of nutritional status (based on the anthropometric measurements) in individual and
the community? These are some of the issues that are covered in this unit.
Unit 8 is a continuation of unit 7, which focuses on the other methods of assessment
of nutritional status in community settings. These include clinical assessment,
biochemical assessment and dietary assessment. Details related to family diet survey,
individual diet surveys and food balance sheets in presented in this unit.
Nutrition monitoring and surveillance are the two major tools involved in knowing
whether the nutritional status of a community is improving or not or what further
actions are required to be taken. Unit 9 deals with these aspects related to nutrition
intervention (both direct and indirect), which appear to have an impact on overall
health and nutrition of vulnerable sections of populations.
Unit 10 is devoted to the study of the intervention programmes and the policy of
the Government of India (GOI), which is designed to ensure good nutritional status
of the population. In 1993, the GOI adopted the National Nutrition Policy (NNP),
in recognition of the magnitude of under nutrition in the country. The salient feature
of the NNP is the major focus in this unit. The national nutrition programmes are
described next.
It is important for us to review whether these programmes have made any impact
in controlling the deficiency diseases or improving the nutritional status of the
population or not? Unit 11, critically analyzes some of the nutrition programmes run
by the government and analyzes their successes and failures. The unit concludes
by presenting the priority actions required to improve nutrition situation in India.
The interventions programmes designed to combat nutritional problems include a
variety of strategies/approaches operating concurrently and attacking various facets
of the causative factors at the same time so that the basic problems are being
modified. What are the possible strategies? What is the basis of these strategies?
These are a few aspects covered in Unit 12 and 13. Unit 12 focuses on the diet
or the food based and nutrient based strategies. The relationship between
immunization and malnutrition, genetics and biotechnology as one of the strategies
to combat malnutrition, role of clean water and sanitation to combat malnutrition
is explored in Unit 13.
Designing and managing the intervention programmes is a crucial aspect in the study
of public nutrition. Recruiting and training of the programme staff is another big
task and a very complex one too. The steps of planning, implementing, and evaluating
a public nutrition programme is discussed in Unit 14. The importance of good
management and governance to achieve the desired results in the communities is
the major focus of the unit.
Finally, nutrition education for behavioural change, is basic to the study of public
nutrition. Units 15 to 18 focuses on the study about the concept, scope, need,
importance and process of nutrition education. The basic concepts related to nutrition
education like need, scope and importance of nutrition education is covered in Unit 15.
The potential challenges and constraints of nutrition education and various theories
of nutrition education is the other aspect covered in this unit. The process of nutrition
education consists of four phases. These are: conceptualization, formulation; 5
implementation and evaluation. Unit 15 presents the details about conceptualization
and briefly introduces the other three phases.
Unit 16, focuses on the formulation of nutrition education programme. Formulation
,means to give shape and structure to the different elements conceptualized during
the process of nutrition education. In this unit we will learn how to design a nutrition
education programme. The unit concludes by discussing how to develop a strategy
to communicate our messages to the target audience.
Unit 17 deals with the implementation of nutrition education programme. The unit
begins with an overview of implementation process. The three main aspects of
implementation process -production/duplication of communication materials, training
and executing a communication intervention - are discussed in this unit.
Once the nutrition education programme has been implemented and has been on
the road for several months it is time to evaluate the programme. Unit 18 describes
the concept and purpose of evaluation and different types of evaluation. How to
develop an evaluation system ? What are the major features of an evaluation
system? How to conduct dynamic and participatory evaluation of a programme.
These, are the major aspects covered in this unit. With this we end our study
of the public nutrition course.
In an effort to facilitate systematic and quick grasp of the different concepts, issues
highlighted in this course, the course booklet has the following additional features:
l A synoptic structure of the unit identifying the themes/sub-themes, an
introduction highlighting the broad area covered within the unit, check your
progress exercises at the end of sections/sub-sections to help recapitulate what
we have learnt so far and also serve as discussion points, a summary at the
end of each unit offering a brief description of the major conclusions, glossary
of important/difficult terms to facilitate understanding of the terms and answers
to check your progress exercises at the end of the unit for easy reference.
l Towards the end of the last unit you will find a list of references under the
title ‘Suggested Readings’.
l At the end of the booklet you will find Annexure 1 and Annexure 2. Annexure
1 is in two parts. Annexure 1A provides guidelines for conducting a diet survey
using 24-hour recall method. Annexure 1B presents the proforma for
assessment of dietary intake of an individual (child) in the family using the
24-hour recall method of diet survey. Annexure 2 gives the schedule for food
frequency questionnaire which can be used for assessment of qualitative dietary
pattern.
l At the end of the booklet a list of abbreviations used in each unit are listed
under the title ‘List of Abbreviations’.
6
Concept of Public
UNIT 1 CONCEPT OF PUBLIC Nutrition
NUTRITION
Structure
1.1 Introduction
1.2 Understanding the Terms: Nutrition, Health and Public Nutrition
1.3 Public Nutrition
1.3.1 Concept
1.3.2 Scope
1.3.3 Future Projections
1.4 Health Care

1.4.1 Concept of Health Care
1.4.2 Levels of Health Care
1.4.3 Primary Health Care
1.4.4 Health Care Delivery
1.5 Role of Public Nutritionists in Health Care Delivery

1.6 Let Us Sum Up
1.7 Glossary
1.8 Answers to Check Your Progress Exercises
1.1 INTRODUCTION
The rapidly changing global trends in the area of food consumption patterns, lifestyles
and environment have a tremendous impact on the nutrition and health profiles of the
communities. Though today’s consumers are much better informed about various issues
relating to their health, the information explosion also adds to the confusion in making
the right choices and staying clear of misinformation and misconceptions. Therein,
emerges the need for professionals with sound knowledge to ensure proper nutrition
and positive health of the people they serve. This need is being felt more acutely in
the current health scenario prevailing all over the world, though the specific issues may
vary from country to country.
In this unit, we will learn about concept of public nutrition. We would learn as to what
public nutrition is all about and why do we want to study it? We will begin by explaining
certain terms used in the area of public nutrition. We will also learn about the concept
and essential component of health care and its delivery. This will help us to understand
the role of public nutritionist in health care delivery.
Objectives
After studying this unit, you will be able to:
l define the terms nutrition, health and public nutrition;
l discuss the concept of public nutrition, its scope and future projections;
l explain the concept of health care and the three different levels at which it is
available to the community;
l describe the health system as it operates in India;
l describe primary health care and the various components of primary health care;
and
l define the role of the public nutritionist in health care delivery.
7
Public Nutrition
1.2 UNDERSTANDING THE TERMS: NUTRITION,
HEALTH AND PUBLIC NUTRITION
You must have used the terms nutrition and health often in your daily life, though not
so often the term “public nutrition”. You might be wondering why we want to learn
about these terms. However, before we study the course of public nutrition in detail,
it is important for us to gain a good understanding of these terms  nutrition, health
and public nutrition in a scientific way. Let us start with the term “Nutrition”.
l Nutrition
You must have studied about the concept of nutrition in the Advance Nutrition Course
(MFN-004). Nutrition is defined as the science of food and its relationship to
health. It is concerned primarily with the part played by nutrients in body growth,
development and maintenance. Good nutrition means, “maintaining a nutritional status
that enables us to grow well and enjoy good health”. The subject of nutrition is very
extensive. Since our concern is with community aspects of nutrition, it is paramount
to understand the other two terms i.e., health and public nutrition. Let us try to
understand what “health” means.
l Health
The most widely accepted definition of health is the one given by WHO (1948) in the
preamble to its constitution. Refer to Box 1 for WHO definition of health.
Box 1 Definition of Health

“Health is a state of complete physical, mental and social well-being and not
merely an absence of disease or infirmity.’’
You should also note that this WHO definition has recently been expanded and includes
“the ability to lead a socially and economically productive life”. However, this concept
of health is considered idealistic by many people and by using this yardstick very few,
if any, would qualify as being healthy. But, if people consciously follow this goal, then
it would enable most people to achieve a more positive state of health. In the absence
of a better way of defining health, this definition of health continues to have universal
acceptance.
Let us now go over to the term public nutrition.
l Public nutrition
Public nutrition is concerned with improving nutrition in populations in both poor and
industrialised countries, linking with community and public health nutrition and
complementary disciplines.
You would note that public nutrition is an applied and very vast field. It includes many
activities as follows:
 an understanding and raising awareness of the nature, causes and consequences
of nutrition problems in society,
 epidemiology, including monitoring, surveillance and evaluation,
 nutritional requirements and dietary guidelines for populations,
 programmes and interventions: their design, planning, management and evaluation,
 community nutrition and community-based programmes,
 public education, especially nutrition education for behavioural change,
8
 timely warning and prevention and mitigation of emergencies, including the use of Concept of Public
emergency food aid, Nutrition
 advocacy and linkage with, for example, population and environmental concerns,
and
 public policies and programmes relevant to nutrition in several sectors, for example,
economic development, health, agriculture and education.
So, we saw that public nutrition is a very vast field and has many aspects to it. We
will now study in detail about the concept, scope of public nutrition and the future
projections of this field.
1.3 PUBLIC NUTRITION

You must have heard of various study areas like “public health nutrition”, “community
nutrition” and “international nutrition”. The concept of public nutrition is already
established under these study areas, so then why do we want to have a separate
course of study. We want to do this so that we develop clarity on our objectives and
action and be effective in improving the nutrition situation of the population. Let us
start with the concept of public nutrition.
1.3.1 Concept
It is widely quoted among applied nutrition professionals that “nutrition is not a
discipline to be studied; it is a problem to be solved.” If this is true, then by
definition, solving nutrition problems requires multidisciplinary cooperation. The study
of nutrition crosses boundaries from the most basic of laboratory sciences to an
understanding of global, economic and political interactions among nations. It is important
for you to understand that nutrition problems in developing, as well as, developed
countries cannot be solved in the laboratory or clinic alone. The constraints to populations
achieving nutritional health fall in the economic, social, cultural and behavioural realms.
Some of these are: the lack of access to food, its inappropriate distribution among and
within households, and maladaptive food and health practices. The skills and knowledge
needed to help address these constraints are quite different from those of the laboratory
scientist or the medical practitioner. They require a different kind of training from that
associated with the science of nutrition.
In a 1996 letter to The American Journal of Clinical Nutrition, Mason and others
suggested the name “public nutrition” to define a new field encompassing the range
of factors known to influence nutrition in populations, including diet and health, social,
cultural, and behavioural factors and the economic and political context. The suggestion
was based on the perception that the field already exists de facto, but that its recognition
as a legitimate field of study would allow education and professional development to
be more explicitly focused on its objectives. Like public health, public nutrition would
focus on problem-solving in a real-world setting, making it, by definition, an applied
field of study whose success is measured in terms of effectiveness in improving
nutritional conditions.
The recognition that nutrition solutions often lie outside the domain of “nutrition” per
se is not new. More recent approaches have been based on the assumption that
nutrition problems will be solved by incorporating nutrition concerns into a wide variety
of disciplines as they are translated into action, for example, when consumption issues
are integrated into agriculture policies. This approach is correct if it can be made to
work, but it is dangerous because nutrition then risks being the responsibility of no one.
Putting nutrition under the domain of health, tends to medicalise the field, while putting
it under agriculture may marginalise it. We need to remember that public nutrition has
a distinct identity, incorporating the relevant aspects of the variety of disciplines that
bear on the nutrition problem, as well as, incorporating scientific advances in the 9
Public Nutrition understanding of nutritional problems. Thus, we saw that although public nutrition is
recognised as a separate field of study, it does incorporate some elements of other
disciplines which contribute to understanding of nutritional problems.
Let us now look at the scope of public nutrition.
1.3.2 Scope
Nutritional status is important as a determinant and correlate of health status and as
a marker of individual welfare, in addition to being an outcome in its own right. A
consequence of emphasising nutrition as the focus of a programme and policy
specialisation may be that solutions then are too often linked to food, failing to integrate
health concerns such as immunisation, environmental sanitation, disease prevention and
treatment, on the one hand, and poverty alleviation, entitlement and empowerment, on
the other. Even in the area of food, many of the region’s major food distribution
programmes are not viewed primarily as nutrition programmes by those who run them,
but as welfare or entitlement programmes.
This raises the question of whether the appropriate field of concentration is one of
nutrition policies and programmes (public nutrition), or whether it would be better
simply to add a nutrition focus to professional training in public health, economics,
political science, or other relevant fields. The field of public nutrition is unique in
requiring at least some understanding of the entire range of determinants of nutritional
outcomes.
The study of these basic determinants extends into areas of economics, agricultural
policy, health science and policy, and the social sciences, as well as, public policy and
management. We need a multidisciplinary approach to solve nutrition problems. Figure
1.1 shows that we need to improve agriculture, education, community development
and health to solve nutrition problems. However, we all tend to stay in our own boxes
and thus confined to our area of specialty.
Agriculturalists assume the solution lies in the food supply, medical professionals assume
the solution lies in health care or supplementation, nutritionists may assume the solution
lies in nutrition education or in food supplements. In any given case, any of these might
be appropriate solutions, but the field requires an empirical outlook to assess the entire
range of possible interventions and policy responses. A basic but thorough understanding
of human nutrition and of the nutritional aspects of food, is also viewed as germane
to address nutrition policies and programme.
Health Community
Financial
Agriculture Education
Education
Figure 1.1 : Public nutrition: the need for cross disciplinary breadth in
understanding nutritional problems
We should have a systematic introduction to the range of programmes and policies that
have affected nutrition in various settings. This introduction should cover design and
implementation issues, specific resource needs, and the conditions under which various
programmes have been found to be more or less effective. Included in this introduction
must not be only nutrition programmes, such as maternal and child health supplementary
feeding, school meals, and nutrition education, but also areas outside nutrition, such as
public health and environmental sanitation, household food and livelihood security, and
food marketing. These programmes should be presented for their direct relevance and
10
to illustrate forcefully the point that nutrition solutions range well beyond the areas Concept of Public
typically defined as nutrition. A great deal of knowledge has been developed through Nutrition
problem analysis, programme evaluations and cost-effectiveness studies; this is clearly
an important knowledge base of public nutrition.
The two areas most commonly identified as important to public nutrition were economics
and behavioural science. Public nutrition as an applied field, need not focus on
econometric analysis or broad economic theory, but on some principles of economics
as it applies to households (the household as a production and consumption unit,
determinants of intra-household allocation, the value of time, the role of incomes,
income sources, and local prices in determining household food security). Some concepts
of political economy  the political forces underlying the economic and social conditions
that relate to the nutritional situation  are generally held to be central to effectiveness
in the field. Understanding the social context of nutrition problems implies knowing the
behavioural and cultural factors that can, directly and indirectly, affect the nutritional
situation of a community (and, more broadly, the country).
Thus, we realise that public nutrition is a very wide field. As a public nutritionist, we
require an understanding of many non nutritional determinants of nutritional outcomes,
in order to solve nutritional problems of population. We also need to have a knowledge
and understanding of programmes and policies which influence nutritional outcomes.
These programmes are both nutritional and non nutritional i.e. education, economics
etc.
Let us now study the future projections in the area of public nutrition.
1.3.3 Future Projections

We discussed earlier that the field of public nutrition has existed for a long time,
although not by this name. A heterogeneous network of professionals with distinct
training and career paths, working in applied nutrition programmes and policy, continues
to shape the field, incrementally, through dedication and effort. Although the need for
a continuing supply of such persons, albeit with more targeted and appropriate training,
is acknowledged widely, funding for the preparation of such individuals is increasingly
scarce. A comprehensive effort in public nutrition would need to address appropriate
training to a critical mass of key individuals at each level of a country. Such a
programme could achieve significant improvement in nutrition and create the human
and institutional capabilities to sustain positive nutritional gains well into the twenty-first
century.
The appropriate training of applied nutrition professionals to work at the programme
and policy levels hence, needs to be supported and recognised. Organisations prepared
to fund this set of training activities will play a significant role in enhancing institutional
effectiveness, strengthen regional capacity for providing ongoing human resource
development, and contribute to the establishment of sustainable training programmes.
Thus, we can appreciate that, as the field of public nutrition gains increasing recognition,
there are more and more opportunities for professionals in the applied field to publish
and disseminate their work in the academic community. There are journals devoted to
food policy and programmes and nutrition journals now commonly contain sections
devoted to the policy and programme applications of nutrition science.
Check Your Progress Exercise 1

1. Define public nutrition.
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11
Public Nutrition
2. Comment on the statement “Public nutrition: The need for cross disciplinary
breadth in understanding nutritional problems.”
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..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
In the next section, we would now learn that nutrition is an essential component of
health care, so it is essential for us to learn what health care means. We will also learn
how health care is delivered in our country and what is the role of public nutritionist
in health care delivery. Let us begin with health care.
1.4 HEALTH CARE

Earlier in this unit, we learnt about the concept of health and what we understand by
being in good health. Now we would learn about importance of imparting good health
to people. We will study about concept of health care, levels of health care, primary
health care and how health care is delivered in India.
Let us start with the concept of health care.
1.4.1 Concept of Health Care

We are aware of the fact that health is a fundamental human right. Thus, it becomes
imperative for the State to assume responsibility for the health of its people. In order
to achieve this objective, globally national governments are engaged in providing adequate
health care to their people. Further, there are continuing efforts to improve these
services.
Box 2 gives the definition of health care.
Box 2 Definition of Health Care
Health care involves much more than just medical care and can be defined
as “multitude of services provided to individuals or communities by agents of
health services or professions, for the purpose of promoting, maintaining,
monitoring or restoring health”.
Medical care, which is by and large seen as the dispensation of services by physicians
themselves or rendered at their instructions, thus becomes a part of the total health
care services. Health care services are usually delivered at three levels. These are
primary care, secondary care and tertiary care levels.
Let us review each of these levels in detail.
1.4.2 Levels of Health Care

It is customary to describe health care services at three levels. i.e. primary, secondary
and tertiary.
Primary level care
This is the first level of contact of an individual, the family and the community with
the national health system. It is possible to deal with most of the health problems of
the community effectively at this level. In India, these services are provided through
a network of Primary Health Centres (PHCs) and their Sub Centres (SCs) spread all
over the country. The functionaries involved in dispensing these services includes
multipurpose health workers, village health guides and trained birth attendants (TBAs
12 or Dais).
Secondary level care Concept of Public
Nutrition
More complex health problems of the community are resolved at the secondary level
care through the district hospitals and the Community Health Centres. The latter are
upgraded Primary Health Centres, which provide a variety of specialist facilities at the
Block level. The Community Health Centres also act as the first referral level. This
implies that patients can be directed to the next level of health care facility without first
going to the district level hospital.
Tertiary level care
This is the highest level of health care available to the community for dealing with their
most complex health problems, which cannot be solved at the primary and secondary
level. The institutions involved in providing the requisite facilities and care include
Medical College Hospitals, All India Institutes, Regional Hospitals, Specialised Hospitals
and other Apex Institutions. These institutions have highly specialised health personnel
who dispense these services.
Figure 1.2 shows three levels of health care. First level - Primary health care includes
promotive, preventive and basic curative health services, second level includes general
hospital services and third level at tertiary health care includes specialised hospital
services.
 Tertiary health care

(specialised hospital)
1%
9%  Secondary health care

(general hospital service)
Primary health care

(promote, preventive and
90%  basic curative corvido at
health posts, health centres
and culture clinics)
Figure 1.2: Levels of Health Care
Since, there are many people in this world, especially in the developing countries, who
do not have access to adequate and quality primary health care, the concept of primary
health care has received world wide attention. We will now study about the concept
of primary health care and its essential components as discussed during the international
conference on Primary Health Care held at Alma Ata, USSR, 1978.
1.4.3 Primary Health Care

The international conference on Primary Health Care held at Alma Ata, USSR, 1978,
focused universal attention on the concept of primary health care as the most effective
means of achieving an acceptable level of health for maximum number of people in
the community. It has been defined as: ‘‘Essential health care based on practical,
scientifically sound and socially acceptable methods and technology made
universally accessible to individuals and family in the community through their
full participation and at a cost that the community and the country can afford
to maintain at every stage of their development in the spirit of self determination’’.
Thus, defined, primary health care becomes a practical approach to provide essential
health care at affordable cost to all the members of the community with their full
participation. The basic tenets of primary health care rest on equitable distribution of
resources, intersectoral coordination, appropriate technology and community participation.
Though all factors are responsible for successful implementation of primary health
care activities, community participation is perhaps the crucial determinant of success
of any developmental programme. It is the process by which individuals and families 13
Public Nutrition assume responsibility for their own health and welfare and for those of the community
and develop the capacity to contribute to their and the community’s development. The
declaration of Alma Ata conference on primary health care is highlighted in Box 3.
Box 3 Declaration of Alma Ata Conference
The declaration of Alma Ata stated that primary health care includes at least:
 Education about prevailing health problems and methods of preventing and
controlling them.
 Promotion of food supply and proper nutrition.
 An adequate supply of safe water and basic sanitation.
 Maternal and child health care, including family planning.
 Prevention and control of endemic diseases.
 Appropriate treatment of common diseases and injuries, and
 Provision of essential drugs.
As you may have read in the declaration, individual countries could add on more
services to this list, but this is the minimum basic health care to be provided to the
population. Indian government has pledged itself to provide primary health care to its
people by signing the Alma Ata Declaration.
Figure 1.3 gives essential components of primary health care and restates that the goal
of primary health care is to provide comprehensive services to actual needs and
priorities of the communities at an affordable price, Immunisation, adequate medical
care, supply of water and adequate sanitation, educating people about the prevailing
health problems, production of food, supply and proper nutrition are some of the
components of primary health care as highlighted in Figure 1.3.
14 Figure 1.3: Essential components of primary health care

Now that we know, what health care means, it is important for us to know how health Concept of Public
care is delivered in our country. Read the next sub-section and find out. Nutrition
1.4.4 Health Care Delivery

The challenge that exists today in many countries is to reach the whole population with
adequate health care services and to ensure their utilisation. Rising costs in the
maintenance of large hospitals and their failure to meet the total health needs of the
community have led many countries to seek alternative models of health care delivery
with a view to provide health care services that are reasonably inexpensive and have
the basic essentials required by the population.
Let us learn about the health system in India.
The Health System in India
The country is divided into 29 States and 7 Union Territories for the purpose of
administration. These are further divided into smaller administrative units called the
districts, which are 718 in number at present. Within the districts are many smaller
demarcated units. One of them is the community development block of which there
are above 6000 in the country. Figure 1.4 gives administrative division of India around
which the health system is based.
Centre
................. ...
29
.
.......................... . ..
States
7 Union
Territories ...
................................... ....
719
Districts
Figure 1.4: Administrative division of India
The main links in the health system comprise the Centre, State, District, Block and the
Village. Since, health is a state subject in India, the states have a considerable amount
of independence in the delivery of health services to their people. Thus, each state has
developed its own system of health care delivery. The centre is responsible for policy
making, planning, guiding, assisting, evaluating and coordinating the work of State
Health Ministries. Thus, it ensures universal coverage of the country with health
services.
Let us review the health system at each of the following links  Centre, State, District
Block, Sub-centre and Village.
Let us start with the Centre.
A. Health System at the Centre
At the national or centre level the health system comprises:
l Union Ministry of Health and Family Welfare
l The Directorate General of Health Services
l The Central Council of Health
Figure 1.5 gives the organs of health system at Central level. It shows three main
organs of health system as listed above. In addition, it shows that Directorate General
of Health Services has 3 Bureaus  namely Bureau of Health Planning, Central
Bureau of Health Intelligence and Central Health Education Bureau. 15
Public Nutrition
Figure 1.5: Organs of health system at central level
Let us look at each of these organs in detail, next.
l Union Ministry of Health and Family Welfare is headed by a Cabinet Minister

and a Minister of State, which are political appointments. The minister is assisted
by the Secretary in the Department of Health and Family Welfare and the Special
Secretary, Family Welfare. The functions of the Ministry include those which are
mentioned in the Union List as the sole responsibility of the Centre as well as
those mentioned in the Concurrent List which are the joint responsibility of both
the centre and the states.
l The Director General (DG) of Health Services acts as the principal advisor to
the Union Government in all matters pertaining to medical and public health area.
Two additional Director Generals and several Deputy Director Generals assist the
DG in performing the various tasks. Further, the Directorate has three Bureaus
namely  Bureau of Health Planning, Central Bureau of Health Intelligence and
Central Health Education Bureau, which have specified roles.
l Central Council of Health comprises all the State Health Ministers under the
Chairmanship of the Union Health Minister.
Let us move on to the state level.
B. Health System at the State Level

Like the Centre, Minister of Health and Family Welfare is head of the Ministry and
the Secretary in the Ministry is the bureaucratic head. The State Health Directorate,
likewise has a Director of Health Services who is the Chief Technical Advisor to the
State Government on all matters pertaining to health. All states also have a Family
Planning Bureau, which is instrumental in the implementation of the Family Welfare
Programme. In addition, there are many specific health programmes which come under
the state health directorate. Figure 1.6 gives organisation of health services at State
level. Some of the specific programmes which come under State Health Directorate
are malaria, tuberculosis, leprosy, blindness control, immunisation and medical care.
16
Concept of Public
Nutrition
Figure 1.6: Organisation of health services at state level
Let us now move on to the district level.

C. District Level of Health System
There are six types of administrative areas, namely  sub divisions, tehsils, community
development blocks, municipalities and corporations, villages and panchayats in a
district. The subdivision and tehsils are progressive divisions of a district where the
tehsil may comprise 200-600 villages. The rural areas are also divided into community
development blocks which comprise approximately 100 villages with about 80,000 to
1,20,000 population.
Each district has an administrative head designated as a Collector. Most districts are
divided into two or more sub divisions each in charge of an Assistant Collector or Sub
Collector. The office of the Chief Medical Officer (CMO) of a district serves as the
nerve centre to integrate all state financed health activities in the rural areas. The
CMO is assisted by a Superintendent for the District Hospital, a District Health
Officer, a District Family Planning Officer and others in the field of malaria, T.B.,
leprosy, school health etc. However, there is no uniform pattern and this may vary
from state to state. Figure 1.7 gives general organisation of health services at district
level and shows Collector being the head administrator.
Figure 1.7: Organisation of health services at district level 17

Public Nutrition Next, let us review the health system at the block level.
D. Health System at the Block Level
A block is generally the unit of rural planning and development under the charge of
a Block Development Officer. Rural areas are divided into Community Development
Blocks which comprise approximately 100 villages and about 80,000 to 1,20,000
population.
The health care infrastructure in rural areas has been developed as a three tier system
including community health centre, primary health centre and sub-centre as highlighted
in Figure 1.8.
Community Health Centre (CHC)

(5624 as on 31 st March, 2017)
A 30 bedded Hospital/Referral unit for 4 PHCs with specialized services
Primary Health Centre (PHC)

(25650 as on 31 st March, 2017)
A Referral Unit for 6 Sub-Centres 4-6 bedded manned with a Medical officer Incharge and 14 subordinates
paramedical staff
Sub Centre
(156231 as on 31 st March, 2017)
Most peripheral contact point between Primary Health Care system & Community manned with one Health
Worker (F) & one Health Worker (M)
Figure 1.8: Rural Health Care System in India
Source : Rural Health Statistics, 2017. Accessed https://daa.gov.in//

catalogue.rural.healthstatistics-2017 on Sept. 2018.
The above illustrated health care system is based on the population norms presented
in Table 1.1.
Table 1.1: Population norms for the three health care
infrastructures in rural areas
Centre Population Norm
Plain Area Hilly/Tribal/Difficult Area
Sub Centre 5000 3000
Primary Health Centre 30,000 20,000
Community Health Centre 1,20,000 80,000
Source: Rural Health Statistics, 2017.
Let us now learn about each system in detail.

Community Health Centre (CHC)
As a part of the overall strategy to improve the basic health services provided
to the community concept of community health centre (CHC’s) was evolved. The
CHC’s manned by four medical specialists i.e. surgeon, physician, gynaecologist
and paediatrician supported by 21 paramedical and other staff (Figure 1.9). It has
30 indoor beds with one operation theatre, X-ray, labour room and laboratory
18
facilities. It serves as referral centre for 4 PHC's and also provide facilities for Concept of Public
Nutrition
obstetric care and specialist consultations.
Figure 1.9: Community Health Centre
Primary Health Centre (PHC)

PHC is the first contact point between village community and the medical officer. As
per minimum requirement a PHC is to be manned by a medical officer supported by
14 paramedical and other staff. Under National Rural Health Mission (NRHM), there
is a provision for two additional staff nurses at PHC’s on contract basis. It act as the
referral unit for 6 Sub-centres and has four to six beds for patients. The activities of
PHC involve curative, preventive, promotive and family welfare service as illustrated
in Figure 1.10. As you can see, they include medical care, family planning, collection
of vital statistics and so on.
Figure 1.10: Functions of primary health centre
Sub-Centre Level
A PHC in a block may not be able to cover the entire 30,000 population, so within the
block, sub-centres are located to provide health care services to smaller population. A
sub-centre is the formal outpost of the existing health delivery system at the
periphery in rural areas. A sub-centre is established for a 5000 population in general
and for a population of 3000 in hilly, tribal and backward areas. There is a male and 19
Public Nutrition female multipurpose health worker posted at each sub-centre. The services provided
at present include mother and child health care, family planning and immunization. It
is proposed to enlarge these to include facilities for intrauterine devices insertions and
simple laboratory investigations like routine examination of urine for sugar and albumin.
Let us move to the last level which is at the grass root level i.e. village level.
E. Health System at the Village Level
There are three functionaries at the village level who are responsible for taking care
of the health needs of the community. These are: 1) Village health guide, 2) Local dais,
and 3) Anganwadi workers. Let us find out who they are and what they do.
1) Village Health Guide
This scheme was launched on October 2, 1977 as a part of the Rural Health Scheme.
The Village Health Guide is not a government functionary, but a volunteer chosen from
the community, preferably a woman, who serves as a link between the community and
the formal health system. She is trained in primary health care at a suitable place and
is expected to do community health work for 2-3 hours daily in the spare time for
honorarium of Rs. 500 per month. The Village Health Guide is capable of taking care
of simple medical ailments and first aid and mother and child health including family
welfare, health education and sanitation. Figure 1.11 shows village health guides taking
care of a person.
Figure 1.11: Village health guide
2) Local Dais
Under the rural health scheme, an extensive training programme has been undertaken
by the government to train all traditional birth attendants (TBAs/Dais) in the country
to improve their knowledge and skills relating to maternal and child health. Thus, every
village should have an access to the service of a trained birth attendant. This will
ensure that home deliveries, which are still a norm in the rural areas, will be performed
under safe and hygienic conditions which will reduce maternal and infant mortality.
3) Anganwadi Worker
Under the ICDS scheme, there is an anganwadi worker for a population of 1000. She
is also an honorary part time worker selected from the community who is responsible
for a package of services delivered at the anganwadi. These include supplementary
nutrition, health check ups, immunization, non-formal preschool education, nutrition and
health education and referral services. The beneficiaries include children below 6
years, pregnant and nursing mothers and women in the age group of 15-45 years.
Along with the Village Health Guide, she constitutes the major link of the community
20 with the health services.
Figure 1.12 shows Health service delivery system in India. It shows linkages between Concept of Public
Nutrition
various functionaries and health institutions at various levels within the state.
State Health State Hospitals

State Directorate Medical Colleges
District Health District Hospitals

District Department
Medical Officer Community Health

Taluka In-charge Centre
Block Medical Officer Primary Health Centre

In-charge
Village Health Workers Sub-centre
Community
Community Health Guide
Trained Dais
Figure 1.12: Health service delivery system in India
We can conclude that government of India tries to ensure universal coverage of health
services for all with special focus on vulnerable population.
We have learnt about the concept and scope of public nutrition and we also learnt about
health care and its delivery system in India. You might be wondering about the role of
public nutritionist in health care delivery. We will find out about it in the next section.
1.5 ROLE OF PUBLIC NUTRITIONIST IN

HEALTH CARE DELIVERY
It is clearly evident from the foregoing discussion that nutrition is an important, though
not the only, determinant of health of an individual. The root cause of many health
problems of the community can be traced to faulty nutrition. It could be a lack, excess
or an imbalance of certain nutrients in the diet, which compromises the nutritional
status leading to health problems. Hence, nutrition can be viewed as a subset of the
health. Since, attainment of health for all is a universal goal of all nations and communities,
public nutrition has to be an integral part of any strategy designed to achieve this goal.
As signatory to the Alma Ata declaration, primary health care becomes the major
approach to achieve an acceptable level of health for maximum number of people in
the community. It has already been stated that the promotion of food supply and proper
nutrition is one of the eight basic essential services included in the primary health care.
Thus, we can conclude that public nutrition is an essential component of health and
health care.
The continuing changes in the health scenario of nations across the world present
varied and newer challenges to the public nutrition professional who is intimately
involved with providing nutrition support in all health care activities. The shift in accent 21
Public Nutrition on health promotion from the earlier one primarily on prevention and cure has added
more responsibilities to all those engaged in health care of the community. Today, much
of the ill health is related to lifestyle and environmental factors whereas a lot of the
illness could be attributed to the causation of germs when the first movement for public
health began. Though the latter has been contained in the developed and less successfully
in the developing nations, the former situation continues to be of concern in the public
health arena. The public nutritionist equipped with the knowledge of food, nutrition and
health is eminently suited to participate in all the strategies of health promotion required
to combat this situation. In the Indian context, where undernutrition is extensively
present in the preschool children and pregnant and nursing mothers on the one hand
and the threat from lifestyle related health diseases like obesity and degenerative heart
diseases show alarming trends on the other, the role of public nutritionist assumes
tremendous importance along with responsibility. A public nutritionist can perform the
following:
l In the hospital-based set up, she is a part of the team delivering therapeutic and
rehabilitative services to the patient. She is responsible for food service management,
nutritional care of the patients including diet counselling and imparting nutrition
education to various categories of medical personnel. The Directorate General of
Health Services has recommended the appointment of at least an assistant dietitian
for every 100 bed hospital with progressive increase in their numbers as the
hospital beds increase.
l There is a role for the public nutritionist in the national health set up at the centre
as the Nutrition Advisor and Research Officer. At the State level, they can
function as the State Nutrition Officers.
l The public nutritionist can make a significant contribution in all the programmes
of development undertaken by voluntary, non-government organizations.
l At the international level organizations like WHO, FAO and UNICEF provide
opportunities for public nutritionists at the policy making, planning and implementation
stages.
From the discussions above, you must have realized that public nutritionist can perform
wide variety of functions ranging from health promotion, curative services to advocacy
and programme planning. So are you ready to take on this role! This course in Public
Nutrition will equip you with the necessary knowledge and skills to function as effective
public nutritionist.
1. Explain the concept of health care and the three different levels at which it is
available to the community.
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
2. List the essential components of primary health care.
...........................................................................................................................
...........................................................................................................................
22 ...........................................................................................................................
Concept of Public
3. What are the health facilities available at the following: Nutrition
i) Sub-centre
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
ii) Village level
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
4. Summarize the activities performed at the PHC level.
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
5. Define the role of the public nutritionist in health care delivery.
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
1.6 LET US SUM UP

We learnt in this unit that public nutrition is concerned with improving nutrition in
populations in both poor and industrialized countries, linking with community and public
health nutrition and complementary disciplines. The challenge that exists today in many
countries is to reach the whole population with adequate health care services and to
ensure their utilization. We also saw that rising costs in the maintenance of large
hospitals and their failure to meet the total health needs of the community have led
many countries to seek alternative models of health care delivery with a view to
provide health care services that are reasonably inexpensive and have the basic essentials
required by the population.
Next, we learnt that primary health care is a comprehensive and alternative approach
to the delivery of health services to the community, in such a way that it is more
Economical and effective with full involvement of local communities. The main links
in the health system comprises the centre, state, district, block and the village.
The continuing changes in the health scenario of nations across the world present
varied and newer challenges to the public nutrition professional who is intimately
involved with providing nutrition support in all health care activities.
The public nutritionist equipped with the knowledge of food, nutrition and health is
appropriately suited to participate in all the strategies of health promotion required to
combat this situation. Finally, we saw that in the Indian context, where undernutrition
is extensively present in the preschool children, pregnant and nursing mothers on the
one hand and the threat from lifestyle related health diseases like obesity and degenerative
heart diseases show alarming trends on the other, the role of public nutritionist assumes
tremendous importance along with responsibility. 23
Public Nutrition
1.7 GLOSSARY
Curative services : the services provided to a person which would enable him
to lead a socially and economically productive life.
Epidemiology : study of diseases or conditions in population.
Health care : the health care services provided to the community.
delivery system It could be governmental or non governmental.
Health guide : a volunteer from the community itself, given orientation
training in health to act as a community level worker.
Promotive services : the services provided to the members of the community to

promote health and healthy habits.
Referral services : the services available at the next higher level of health
institutions.
1.8 ANSWERS TO CHECK YOUR PROGRESS

EXERCISES
1. Public nutrition is concerned with improving nutrition in populations in both poor
and industrialized countries, linking with community and public health nutrition and
complementary disciplines. It has a distinct identity, incorporating the relevant
aspects of the variety of disciplines that bear on the nutrition problem, as well as
incorporating scientific advances in the understanding of nutritional problems.
2. Public nutrition encompasses a range of factors known to influence nutrition in
populations, including diet and health; social, cultural, and behavioural factors; and
the economic and political context. Public nutrition would focus on problem-
solving in a real-world setting, making it, by definition, an applied field of study
whose success is measured in terms of effectiveness in improving nutritional
conditions. More recent approaches have been based on the assumption that
incorporating nutrition concerns into a wide variety of disciplines, as they are
translated into action, will solve nutrition problems.

1. Health care involves much more than just medical care and can be defined as
“multitude of services provided to individuals or communities by agents of health
services or professions, for the purpose of promoting, maintaining, monitoring or
restoring health.” It is customary to describe health care services at three levels
viz. primary, secondary and tertiary.
Primary care level is the first level of contact of an individual, the family and the
community with the national health system. The functionaries involved in dispensing
these services include the multipurpose health workers, village health guides and
trained birth attendants (dais).
Secondary level care takes care of more complex health problems of the community
through the district hospitals and the Community Health Centres. The Community
Health Centres also act as the first referral level.
Tertiary level care is the highest level of health care available to the community
for dealing with their most complex health problems, which cannot be solved at
the primary and secondary level. The institutions involved in providing the requisite
facilities and care include Medical College Hospitals, All India Institutes, Regional
24 Hospitals, Specialized Hospitals and other Apex Institutions.
2. The essential components of primary health care include: Concept of Public
Nutrition
l Education about prevailing health problems and methods of preventing and
controlling them.
l Promotion of food supply and proper nutrition.
l An adequate supply of safe water and basic sanitation.
l Maternal and child health care, including family planning.
l Prevention and control of endemic diseases.
l Appropriate treatment of common diseases and injuries, and
l Provision of essential drugs.
3. The health facilities available at the sub-centre and village level are:
Sub-centre : Treatment of minor ailments, First aid for accidents and
emergencies, health education activities, chlorination of water
resources, immunization and family planning services
Village level : Treatment of minor ailments, MCH and family planning,
Environmental sanitation
4. The activities performed at the PHC level include curative services, preventive
and promotive aspects of health care, Organization of training programmes,
continued education activities for the sub centre staff and health functionaries at
the village level, and referral services.
5. A public nutritionist in health care delivery can perform the following roles:
l In the hospital-based set up she is a part of the team delivering therapeutic
and rehabilitative services to the patient. She is responsible for food service
management, nutritional care of the patients including diet counselling and
imparting nutrition education to various categories of medical personnel.
l There is a role for the public nutritionist in the national health set up at the
centre as the Nutrition Advisor and Research Officer. At the State level,
they can function as the State Nutrition Officers.
l The public nutritionist can make a significant contribution in all the programmes
of development undertaken by voluntary and non-government organizations.
25
Public Nutrition
UNIT 2 PUBLIC NUTRITION:
MULTIDISCIPLINARY CONCEPT
Structure
2.1 Introduction
2.2 Multiple Causes of Public Nutrition Problems
2.3 Multidisciplinary Approach to Solve Nutrition Problems
2.4 Role of Agriculture in Nutrition
2.5 Distribution of Food Products
2.6 Storage of Food
2.7 Application of Science and Technology to Improve Food Supply
2.8 Food and Nutrition Security
2.8.1 Understanding the Concept of Food and Nutrition Security
2.8.2 Determinants of Food Security
2.8.3 India’s Food Security System
2.9 Sustainable Development Goals
2.10 Food Behaviour
2.11 Let Us Sum Up
2.12 Glossary
2.1 INTRODUCTION
We have read in Unit 1 that public nutrition is concerned with improving nutritional
problems of population. We also learnt that public nutrition requires knowledge of
many disciplines and involvement of multiple sectors for addressing nutrition problems
of population. Thus, policies and programmes planned to address dietary and nutrition
problems may draw upon disciplines well outside the traditional boundaries of nutrition.
For example, evaluation of the nutritional effectiveness of a supplementary feeding
programme or predicting the nutritional consequences of changing price policies may
require inputs from economics, behavioural sciences etc. In this unit, we will study
about multiple causes of malnutrition and will also examine the multidisciplinary
approaches and their intersectoral linkages to solve nutritional problems. Since there
are many disciplines which need to be involved in addressing the problems of
malnutrition, in this unit we will limit ourself to the role of agriculture and the related
issues. We will learn how agricultural and horticultural production, distribution and
storage of food products influence food consumption and nutritional status of population.
We will also learn how application of science and technology in agriculture can
improve food production. Further, the unit will introduce the concept of food and
nutrition security and how various factors i.e. gender, economic etc have an impact
on food and nutrition security. We will conclude the unit by discussing the food related
behaviours and its multiple determinants.
Objectives
l discuss multiple causes of malnutrition and the multidisciplinary approaches to
26 solve these problems;
l describe the influence of agricultural and horticultural production, storage, distribution Public Nutrition :
and science and technology on food consumption and nutritional status of the Multidisciplinary
Concept
population;
l explain food and nutrition security and the underlying economic and social conditions
as related to food security; and
l define food behaviour and describe the social, cultural and psychological
determinants of food behaviour.
2.2 MULTIPLE CAUSES OF PUBLIC NUTRITION

PROBLEMS
We read in Unit 1 that the field of public nutrition is unique in requiring at least some
understanding of the entire range of determinants of nutritional outcomes. To clearly
understand what causes nutrition problems, it is necessary to consider the operation
and interaction of various determinants of malnutrition at different levels in society.
The food – health – care conceptual framework portraying causal factors and their
interaction is depicted in Figure 2.1, which shows causes of malnutrition at three levels
– immediate causes, underlying causes and basic causes. Immediate causes exist at
individual level, while underlying and basic causes exist at family and societal level,
respectively. The multisectoral nature of malnutrition becomes obvious when we look
at the underlying causes. These causes are numerous and usually interrelated. The
exact causes can be identified only in a particular context. To simplify the analysis
these may be grouped into three main clusters: basic health services and a healthy
environment, household food security, and maternal and child care. Most underlying
causes are themselves the result of unequal distribution of resources in society. This
disparity has to be analyzed, understood and acted upon. Causes at this level are either
basic or structural.
OUTCOMES Malnutrition, Disability and Death

Immediate 1) Inadequate dietary intake
Causes at 2) Disease
Individual Level
Underlying 1) Insufficient access to FOOD
Causes at 2) Inadequate maternal and child CARING practices
Household/ 3) Poor water/sanitation and inadequate HEALTH services
Family Level 4) Inadequate and/or inappropriate knowledge and
discriminatory attitudes limit household access to actual
resources
Basic Causes 1) Quantity and quality of actual resources – human, economic
in Society and organizational and the way they are controlled
2) Political, cultural, religious, economic and social systems
including status of women, limit the use of potential
resources
3) Potential resources : environment, technology, people
Adapted from UNICEF (1998) The State of World’s Children 1998.Oxford University Press
Figure 2.1 : Causes of Malnutrition – A Conceptual Framework
The study of these basic determinants extends into areas of economics, agricultural
policy, health science and policy, and the social sciences, as well as public policy and
management. So, it is obvious that there are multiple determinants of nutritional problems
and accordingly we need to adopt a multidisciplinary approach to solve the public
nutrition problems. We will now study about the multidisciplinary approaches to solve
nutritional problems. 27
Public Nutrition
2.3 MULTIDISCIPLINARY APPROACH TO SOLVE
NUTRITION PROBLEMS
You must have realised by now that solving public nutrition problems represents a
multidisciplinary challenge of large magnitude and therefore requires a multidisciplinary
approach to find a solution. Science and technology have been able to make meaningful
contributions to socioeconomic development only when they have acted in an
interdisciplinary manner to solve the problems. Hence, there is a need to recognize
the value of such an approach and give special attention to organizing activities that
would involve teams of scientists (both social and natural), technologists, policy-makers
and planners (including development economists) and the implementers of programmes
to collectively look into the major problems of mankind and find solutions for them
through co-operative efforts. The concerned disciplines should stimulate each other
consciously and create a comprehensive and dynamic system capable of multidisciplinary
action that could increase the pace of progress towards establishment of a more
equitable and just social order in this world. This effort could convert the vicious cycle
in which we are caught at present into dynamic development cycles. There are many
kinds of disciplines which have an impact on nutrition. However, in this unit we would
limit ourselves to the discipline of agriculture and science and technology as used to
improve agriculture. In the coming section, we will study, how agriculture and horticulture
production, storage, distribution of food products and science and technology influence
food consumption and nutritional status of the population? And how can all these fields
interact with each other in order to benefit society? In the next section, we will try to
find answers to some of these questions. Let us start with the role of agriculture in
improving nutrition.
2.4 ROLE OF AGRICULTURE IN NUTRITION

You may be aware that nutrition is an important environmental factor that influences
health and well-being of people. Consumption of diets, adequate both in quantity and
quality, is a prerequisite for the maintenance of good nutritional status. Agricultural
production that determines food availability is, therefore, an important determinant of
food consumption, though not a critical one if food imports can be assured. Self-
sufficiency in food production is of particular importance for developing countries, not
only because they tend to have high rates of population growth, but also because such
countries have malnutrition as a public health problem. The quantitative aspects of food
production are undoubtedly of primary concern, but it cannot be forgotten that the
qualitative aspects are extremely important, if optimal nutrition is to be provided. The
interphase between agriculture and nutrition, therefore, acquires considerable practical
importance. We will study issues related to food grains and horticultural products (fruits
and vegetables) their storage and distribution and see how they affect the consumption
pattern of population. Let us study the issues related to food grains.
Issues relating to food grains and Green Revolution
Food production in India has increased substantially over the years. One of the major
achievements in the last 50 years has been the Green Revolution and self-sufficiency
in food production. The green revolution has been most striking in the areas of wheat
production where yields have increased consistently over the years to reach an average
of 3216 kg/hectare in 2016-2017 from a figure of 827 kg/hectare in 1965-66. Coupled
with an almost two fold increase in the area under cultivation over the same time
period, the total production of wheat has increased five fold. The rice yields have not
been comparable though the area under rice cultivation has also increased, but at a
much slower rate. In the case of coarse cereals, an almost stagnant area under
cultivation leading to a production figure of around 20-30 million tonnes over the last
three decades offsets the small increase in productivity.
28
The nutritional status of a population is largely determined by the quality and quantity Public Nutrition :
of food consumed by the individual members. The per capita availability of food is an Multidisciplinary
Concept
important, though not the sole, determinant of the pattern of consumption. This is a
function of food grain production and growth of the population. India's current yearly
growth rate is 1.11%. India's total food grain production has increased at an annual
growth rate of 2.68% since 1960-61.
National Food Security Mission (NFSM) was launched in 2007-08 to increase the
production of rice, wheat and pulse. The mission resulted in bumper increase in production
of wheat (104.41 million tonnes), rice (92,29 million tonnes) and pulses (16.35 million
tonnes).
Figure 2.2: Agricultural Production (million tonnes)
Source: Ministry of Agriculture; PRS.
At the national level, food production appears to be sufficient to meet the country’s
needs. In actual practice, however, food consumption does not follow normal distribution
but is skewed. In the last two decades, there has been a progressive decline in pulse
consumption, especially among the poor segments of the population. A large number
of families with a daily income of Rs. 2 or less consume diets that do not provide
enough energy, and of these, a proportion do not get enough proteins – a finding that
explains widespread PEM among young children. The primary reason for such
inequitable distribution is lack of purchasing power. The impressive stocks of food
grains, held in recent years, is, in fact, a reflection of this low buying power and
consumption. Stocks would have been far less impressive if people could have
afforded to buy what they needed. Wages and incomes have gone up over the years
but they do not seem to have kept pace with the rising costs of even essential food
commodities. Data collected by the National Nutrition Monitoring Bureau show that
food consumption has not changed significantly over the last few years. To illustrate,
preschool children constitute one of the most nutritionally vulnerable segment of the
population and their nutritional status is considered to be a sensitive indicator of
community health and nutrition. There, has not been a substantial improvement in
their nutrient intake, particularly the energy intake over the last two decades as can
be seen in Table 2.1.
Due to increased agricultural production in the country, food grain imports have
progressively come down and, during recent years, have all but stopped. The agricultural
situation has also been able to prevent the serious widespread famines that used to
occur in earlier years. Both are no mean achievements. But increased production
seems to have made a little impact on the widespread chronic malnutrition in the
country, with all its health and developmental implications.
29
Public Nutrition Table 2.1: Average nutrient intake among preschool children
Nutrients 1-3 years 4-6 years
1988-90 1996-99 2011-12 1988-90 1996-99 2011-12
Protein (g) 23.7 20.9 21.3 33.9 31.2 30.3
Energy(Kcal) 908 807 767 1260 1213 1082
Calcium (mg) 256 239 247 147 298 263
Iron (mg) 10.2 8.7 5.8 15.3 14.3 8.9
Thiamine (mg) 0.52 0.40 0.50 0.83 0.70 0.80
Riboflavin (mg) 0.37 0.4 0.4 0.52 0.60 0.50
Niacin (mg) 5.56 4.60 5.3 8.40 7.4 8.2
Vitamin C (mg) 14 15 16 23 25 25
VitaminA(µg) 117 133 151 153 205 177
Source: Nutrients Requirement and Recommended Dietary Allowances For Indians, 2010.
Inspite of huge buffer stocks, 8% of Indians do not get two meals a day and there
are pockets where severe undernutrition takes their toll even today. Every third child
born is underweight. About 37.5% of the preschoolers suffer from undernutrition.
Micronutrient deficiencies are widespread. Undernutrition associated with HIV/AIDS
will soon emerge as a public health problem. Alterations in lifestyle and dietary intake
have lead to increasing prevalence of obesity and associated non-communicable diseases.
In the new century, the country will have to gear itself to prevent and combat the dual
burden of under and over-nutrition and associated health problems.
Increased agricultural production is a key factor in ensuring adequate food supplies.
The agricultural policy of a country will have to take care of the relevant aspects of
its nutrition policy, if the food needs of the population have to be met. Imbalances in
production of different commodities have to be corrected and more importantly, food
has to be made available at a cost that the great majority can afford. Until such time,
adequacy of agricultural production will be more apparent than real. It must not be
forgotten that factors outside agriculture also have a role in influencing nutrition.
Thus, from our discussion above, it is evident that although food grain production has
considerably increased at national level over the last 50 years, we have large number
of people in our country who do not consume diets with adequate calorie and protein
intakes. Next, let us now look at issues related to horticultural products and how they
influence consumption levels of population.
Issues related to horticultural products
We know that vegetables and fruits constitute an integral part of the predominantly
vegetarian Indian dietary pattern. They provide the much-needed variety to the otherwise
typical cereal pulse meal pattern practiced in most Indian homes. An area of 24.9
million hectares (2016-17) roughly comprising 10% of the total cropped area of the
country is utilized for growing horticultural crops. India is the second largest procedurs
of vegetables with 2.8% of total cropped area under vegetables. Production of fruits
is estimated to be 92 million tonnes. Currently India ranks second in fruit and vegetable
production after China with a figure of 90.2 and 169.1 million metric tonnes of production
respectively.
However, per capita consumption of these in the country is very low. The nutritional
intake from fruits and vegetables is higher among urban population than that of rural
population. Consumption of adequate quantities of vegetables, especially, green leafy
vegetables is essential for meeting the dietary requirements of vital micronutrients.
Besides, vegetables also provide several phytochemicals and fibre. At present, there
is an insufficient focus on the cultivation and marketing of low cost locally acceptable
30 green leafy vegetables, yellow vegetables and fruits. As a result, these vegetables
are not available at affordable cost throughout the year. Health and nutrition education Public Nutrition :
emphasizing the importance of consuming these inexpensive but rich sources of Multidisciplinary
Concept
micronutrients will not result in any change in food habits unless the horticultural
resources in the country are harnessed and managed effectively to meet the growing
needs of the people at an affordable cost. Horticultural products provide higher
yields per hectare and sell at higher prices. The processing, storage and transportation
of horticultural products in a manner so that there is no glut and distress sales will
make their production economically attractive to farmers and improve availability to
the consumers. Thus we may conclude that horticultural products are not available
to the population at affordable costs throughout the year. This affects the consumption
level of these items and contributes to poor quality diets. You would also like to
know that even when food is available, it may not be equitably distributed amongst
different members of the family. This brings us to the next issue related to distribution
of food. Let us read about it now.
2.5 DISTRIBUTION OF FOOD PRODUCTS

We learnt earlier that we have buffer stocks of food grains in our country. These
stocks do help to combat acute transient food scarcity, caused by natural disasters like
floods and droughts. Early warning systems are in place and food can be rushed to
areas of threatened distress fairly rapidly. What is proving more difficult is the task of
combating chronic mild/moderate undernutrition in a large number of poor households.
Inequitable distribution of available food among different segments of the population
and even within the family is one of the major factors responsible for undernutrition/
overnutrition. Good governance and health and nutrition education hold the key to
improving equitable distribution of food based on need. However, it is not just distribution
but the proper storage of food which is also important. This will influence the food
availability and food consumption pattern of people. Let us look at the issues related
to storage of food products next.
2.6 STORAGE OF FOOD PRODUCTS

After the food has been harvested, it reaches the consumer after undergoing various
processes to make it acceptable and palatable to the consumers. Efforts to augment
Harvesting

Pre-drying in field

Threshing

Winnowing

Drying

Storage
(sacks, bags, bulk)

Primary processing
(cleaning, grading, hulling, pounding milling)

Secondary processing
(cooking, blending, fermentation)

Packaging and Marketing
Figure 2.3: Flow chart for post harvest system by food commodity 31
Public Nutrition the food resources of the community can fulfill the goals of meeting the food and
nutritional requirements of the population, only if they are matched with technologies to
prevent and reduce the post harvest losses caused by a variety of physical, biological
and mechanical factors. Such losses include not only the quantitative aspects but also
the deterioration in quality of foods, which may render them inedible for human
consumption or lead to serious health consequences, if consumed.
After production, food goes through various activities like preprocessing, transportation,
storage, processing and packaging and marketing as illustrated in Figure 2.3, before it
reaches the consumer in the community. The magnitude of losses incurred will depend
upon the nature of the food commodity – whether perishable, semi perishable or more
stable, as well as, the intensity of the physical and biological factors. It is well recognized
that socioeconomic and political forces, regulations and other bureaucratic procedures
slow down the passage of food from the producer to the consumer. An accurate
estimate of such losses is difficult to measure though figures adding up to a staggering
40% or more have been reported from several countries in the developing regions.
Various studies have reported food losses during different operations such as 1-5% loss
in harvesting, 1-6% loss in frying, 2-7% loss in transportation, 2-5% loss in storage, 2-
6% loss in threshing and 2-10% loss in milling and premilling in paddy crops in India.
Thus, storage of food is an important link in the chain of events leading to the ultimate
delivery of food at the consumer level.
Thus, we see that post harvesting lossess may account to 40% or more after the food
is produced and reaches the consumer. Next thing which comes to our mind is that if
we reduce the post-harvesting losses, we will have more food available to the people.
So, how can we reduce these post harvesting losses? We can do that by using innovative
techniques offered by science and technology. Let us find out about it in the next
section.
2.7 APPLICATION OF SCIENCE AND

TECHNOLOGY TO IMPROVE FOOD SUPPLY
The solution to food and nutrition problems requires a sound understanding of the
interface aspects, in which agricultural scientists, food technologists, nutritionists and
others concerned would constantly interact with each other to ensure a multidisciplinary
system and work as an interdisciplinary team in a concerted manner. Only through
such programmes of action can the total agro-economic system contribute to bringing
about the socio-economic transformation of the developing countries, and provide the
stimulus that can overcome poverty through acceleration of the development process.
The problems involved in bridging the wide gap between the national nutritional needs
of the developing countries and available food supplies can be approached by the
following lines of action, which can be taken up simultaneously: (a) increasing food
production through better agricultural technology (b) ensuring effective conservation
and utilization of foods through the application of modern technology.
The last 30 years have witnessed spectacular increases in food-grain production in
India. A sizeable buffer stock has also been built up to face the likely shortages arising
out of uncertain production levels. Breeding of new food-grain varieties have been
directed to increasing per hectare yields and resistance against field-borne microorganisms
and insect pests.
Advances in food technology and nutrition have, however, given some insight into the
desirable features that need to be considered in breeding programmes. The impressive
growth in food-grain production during the last 30 years has resulted from increases in
the area under cultivation for food-grain crops, improvement in per hectare yield,
introduction of high-yielding varieties, particularly of wheat and rice and provision of
irrigation and other inputs. Maximum productivity has been sought by judicious water-
management practices, appropriate cropping systems (double, triple, and multiple) under
32
dry and irrigated conditions, improved dry land agriculture (mulching, recycling of Public Nutrition :
runoff water to provide supplementary irrigation, and choice of crop compatible with Multidisciplinary
Concept
season), intercropping, multilevel cropping and mixed farming practices.
About 70 percent of food grains produced in India are retained for farm-level consumption
and the rest moves along a chain of agencies before it reaches the consumption points.
Post-harvest conservation by modern procedures is, therefore, a crucial need to prevent
the dissipation of national efforts to raise food production levels. The incidence of bunt
in wheat, chalky grains in rice, and gibberella infection in maize, and the impairment
of processing qualities as a result of pre-harvest infection have engaged the attention
of scientists in recent years. The expertize in food conservation built up during the last
30 years has found increasing application, but basic information to evolve varieties with
desirable storage, processing, and nutritional or organoleptic qualities is important in
meeting future needs. Variable production levels in different years emphasize the need
for varieties that give maximum yields during processing and suffer minimum losses
during post-harvest handling and storage.
Post harvest losses especially in vegetables and fruits are presently in the range of 20-
30 per cent. They contribute directly to higher costs and reduce availability of these
commodities. Precision farming and processing based on science and technology are
both intellectually stimulating and economically rewarding as they would enable the
micronutrient needs of the population to be met through a sustainable food based
approach. Thus, we see that the application of modern scientific methods can improve
the food supply and make more food available to the consumers. This brings us to the
next issue of how consumers can feel more secure in terms of food availability,
accessibility and consumption. We will cover this issue in detail in the next section. But
first let us review what we have learnt so for by answering the questions given in
check your progress exercise 1.

1. How can a multi sectoral approach help to solve nutritional problems?
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
2. Read the following statements carefully. State if they are true or false. Correct
the false statement.
a. In spite of having sufficient food stocks at national level, large number of
people still do not consume diets with adequate calories and protein.
................................................................................................................
................................................................................................................
b. India ranks only second to China in vegetable production, hence per capita
consumption of vegetables is very high in India.
................................................................................................................
................................................................................................................
c. Distribution of available food among different segments of the population
and even within the family fairly equitable and not an issue for undernutrition/
over nutrition.
................................................................................................................
................................................................................................................
................................................................................................................
33
Public Nutrition
d. Post harvest losses especially in vegetables and fruits are presently in the
range of 20-30 per cent.
................................................................................................................
................................................................................................................
3. How can science and technology help to improve food supply?
.......................................................................................................................
.......................................................................................................................
..........................................................................................................................
2.8 FOOD AND NUTRITION SECURITY

In the previous section, we learnt about the trends in production of food grains in the
country and their relationship to population growth reflected in per capita availability.
The concept of food security at the national level essentially implies how well a country
is equipped to provide sufficient food to its population. We will now learn what we
mean by the term food security and the factors, which determine food security. We
will also study about India’s food security system.
2.8.1 Understanding the Concept of Food and Nutrition Security

Food security may be defined as a physical and economic access by all people, at
all times, to sufficient food to meet their dietary needs for a productive and
healthy life. The most widely quoted definition of food security is that of the World
Bank: “Access by all people at all times to enough food for an active, healthy
life.” The concept of food security aims at removing the imbalance between the
demand and supply of food. Thus, it is not merely availability of food for direct
consumption, but also includes the means to buy it. Although national food security is
important as providing a foundation, what is more important is food security for each
and every household and within it to every member of the family. A household is food
secure when it has access to food that is adequate in terms of quality, quantity, safety
and cultural acceptability for all its members. We also want to ensure that family
members keep up in good health after consuming the food. This brings us to the issue
of nutritional security. Let us understand this concept.
Understanding nutrition security
Food security is a part of the broader concept of nutrition security. A household can
be said to be nutritionally secure if it is able to ensure a healthy life for all its members
at all times. Nutritional security can be briefly defined as a balance between biological
requirements in energy and nutrients and the quantity and quality of foods
consumed. Nutritional security thus, requires that household members have access
not only to food, but also to other requirements for a healthy life, such as health care,
a hygienic environment and knowledge of personal hygiene. Food security is a necessity
but insufficient condition for ensuring nutrition security. There are some factors that
determine food and nutrition security. What are they? Let us find out in the next section.
2.8.2 Determinants of Food Security

We learnt above that there is also a qualitative aspect to food security, which compels
the perception of food not only as a square meal or two but the exquisite balance of
calories, proteins and micronutrients that enables women to stay healthy and bear
healthy babies, toddlers to grow to their best potential, adolescent girls to grow up
healthy, elderly to live quality healthy life and adult men and women to work to their
optimum productivity. A national balance sheet pointing to comfortable food stocks and
adequacy in food grain production does not constitute food security and nutritional
34 adequacy at the household or individual level. Though national granaries may be filled
and markets stuffed with food, it does not follow that all people have adequate access
to it. More than food production, food security is related to who consumes food and Public Nutrition :
who has the purchasing power to buy it. It is also about what kind of food is eaten, Multidisciplinary
Concept
when and by whom. It is about how the food is prepared, stored and administered with
what level of knowledge. Equally, it is about how well a food is absorbed and what
reinforcement it receives from the surrounding quality of health, hygiene, sanitation and
the physical, as well as, cultural environment. Food security essentially is the combined
product of four factors:
 Food availability,
 Food access,
 Food utilization, and
 Vulnerability
Let us study these factors in detail:
1. Food Availability: It depends on the quantum and quality of crops, livestock,

fishery and other food sources, as well as commercial imports or food assistance.
Food available is achieved when sufficient quantities of food are available to all
individuals within a country.
2. Food Access: Food access is linked to its affordability. Food access is ensured
when households and all individuals within them have adequate resources to
obtain appropriate food for a nutritious diet. The poor and the marginalized sections
need assisted external intervention to enable them to purchase food.
3. Food utilization: It is the proper biological use of food, requiring a diet providing
sufficient energy and essential nutrients, potable water and adequate sanitation.
Effective food utilization is directly influenced by dietary patterns and preferences,
nutrition knowledge and caring practices at the community, household and individual
level. Intra-household distribution of food is determined by gender and age
preferences and adversely influences access to food by women and children.
4. Vulnerability: It is the fourth critical variable and defines the risk factor to which
a person, family, community or nation is exposed on account of extraneous and
intrinsic contextual reasons. Children, adolescent girls, expectant and nursing
mothers and those who inhabit disaster prone and harsh climatic regions are more
at risk than others of not getting sufficient and adequate food.
Having learnt about the factors above, the disturbing truth is that those who are food
insecure suffer not only from the poor access of food but also its poor utilization. Over
the past decade, UN agencies and the Government of India (GOI) have built convincing
evidence to show how nutritional practices, disbursement of food within the household
and physiological absorption undermine the impact of what is consumed. There are
several determinants which impact the various aspects of food and nutrition security.
We focus our discussion on the main determinants as follows:
-- Inappropriate caring and feeding practices
-- Gender discrimination
-- Unsafe water and sanitation
-- Natural disasters
A rereview on these determinants follows:
— Inappropriate caring and feeding practices
Data from National Family Health Survey (NFHS-4, 2015-16) shows that 37.5% of
children under 5 years of age are underweight, 38.4% stunted and 21% wasted, with
7.5% severely wasted. It also shows that more than 50% pregnant women and 58.5% 35
Public Nutrition children aged 6-59 months suffer from anaemia and a significant number from Vitamin
A and iodine deficiency, so it becomes clear that the food basket, as it exists today,
is not being wisely constructed, tapped, processed or absorbed. Indian malnutrition, as
elsewhere, is unmistakably linked to inappropriate caring and feeding practices. In turn,
these practices are a product of uninformed caregivers, overwhelmingly women.
Conversely, where female literacy is high, there is a proportional decline in the level
of malnutrition. Let us look at the next determinant.
— Gender discrimination
Of the detrimental factors, that affect food security, gender discrimination is the most
pervasive and vicious. The fact that households and society favour males with higher
quality and quantity of food intake, grooming women to eat last and least is the key
reason for greater female deaths among under five year old children, as also higher
rates of malnutrition, morbidity and mortality among women. The Indian sex ratio
(census 2011) continues to favour males (946 females per thousand males).
— Unsafe Water and sanitation
Safe water and sanitation may seem tenuous in their link to food security but their
impact is unquestionable. With 19% Indian population still without any source of safe
water and 84% without access to sanitation, the security of food gets quickly questioned
if not eroded.
— Natural disasters
Disaster prone settings also shape the intensity and prevalence of food insecurity.
These consist of poor who are exposed to recurrent natural disasters, which undermine
their already low food intake and nutritional status and accentuate their vulnerability
to food insecurity.
The concept of food security showing the variables central to its attainment is shown
in Figure 2.4. The figure shows that food security is related to education/skill levels,
gender and nutrition knowledge, in addition to the provision of enough food supply. It
is also related to unhygienic living, lack of health infrastructure and health care.
Ultimately, it is related to failure of governance at various levels.
Food Security
 Food Availability
 Food Access Food Absorption

Education/Skill Gender
 
PDS Facility Livelihood Access Nutrition Status 
Food Production  Wage/Self Employment  Nutrition Knowledge



Disaster Urban/Rural Health Infrastructure

Infrastruture
Figure 2.4 : Food security – concept diagram
Source: Adapted from Food Security Atlas of Rural India.

36
Thus we saw that, countering food insecurity is not only a challenge of providing more Public Nutrition :
food to the least privileged Indian households but of making a concerted convergent Multidisciplinary
Concept
attack on gender bias and climatic, environmental, social and other discriminatory
factors. Let us now study how India is making attempts to cope up with large problem
of food insecurity of its people.
2.8.3 India’s Food Security System

The importance of optimal nutrition for health and human development has been well
recognized by the Government of India. At the time of independence, the country
faced two major nutritional problems. The first problem was threat of famine and the
resultant acute starvation and the lack of an appropriate food distribution system. The
second problem was chronic energy deficiency due to:
 Low dietary intake because of poverty and low purchasing power,
 High prevalence of infection because of poor access to safe drinking water,
sanitation and health care, and
 Poor utilization of available facilities due to low literacy and lack of awareness.
The major public health problems were chronic energy deficiency, kwashiorkor,
marasmus and micronutrient deficiencies such as goiter, beriberi, night blindness and
anaemia. After independence, the country adopted multisectoral, multipronged strategy
to combat these problems and to improve the nutritional status of the population.
Improving the health of its people became a very important issue, and it was even
included in the Constitution of India as follows:
Article 47 of the Constitution of India states that “the State shall regard raising
the level of its people and improvement in public health among its primary duties.”
Thereafter, successive Five-Year Plans laid down the policies and strategies for achieving
the goals of improving the nutritional and health status of people of India. The Green
Revolution ensured that the increase in food production stayed ahead of the increase
in population. The country has now moved from chronic shortages to an era of surplus
and export in most items. The country is self-sufficient in food grain production. Along
with the steps to achieve adequate production, initiatives were taken to reach foodstuffs
of right quality and quantity to the right places and persons at the right time and at an
affordable cost.
Government has notified the National Food Security Act, 2013 on 10th September,
2013 with the objective to provide for food and nutritional security to all by ensuring
access to adequate quantity of quality food at affordable prices to people to live a life
with dignity. The Act provides for coverage of upto 75% of the rural population and
upto 50% of the urban population for receiving subsidized food greens under Targeted
Distribution System (TPDS), thus covering about two-thirds of the population. The
eligible persons are entitled to receive 5 Kgs. of foodgrains per person per month at
subsidised prices of Rs. 3/2/1 per Kg for rice/wheat/coarse grains, respectively. The
existing Antyodaya Anna Yojana (AAY) households, which constitute the poorest of
the poor, will continue to receive 35 kgs of foodgrains per household per month.
The Act, also has a special focus on the nutritional support to women and children.
Besides meal to pregnant women and lactating mothers during pregnancy and six
months after the child birth, such women are also be entitled to receive maternity
benefit of not less than Rs. 6,000, children upto 14 years of age are entitled to
nutritious meals as per the prescribed nutitional standards. In case of non-supply of
entitled foodgrains or meals, the beneficiaries will receive food security allowance.
37
Public Nutrition
Box 1 Salient features of National Food Security Act (2013)
 Coverage and entitlement under Targeted Public Distribution System (TPDS)
 Subsidised prices under TPDS and their revisions - Food grains are available
at subsidized prize of Rs. 3/2/1 per kg for rice/wheat/coarse grains for a
period of 3 years from date of commencement of the Act.
 Nutritional support to women and children - Pregnant women and lactating
mothers and children (6-14 years) are entitled to meals as prescribed under
MDM and ICDS schemes.
 Maternity Benefits - Pregnant women and lactating mothers are provided
with facility to receive maternity benefit of not less than Rs. 6000/-.
 Women Empowerment - Eldest women of the household of age 18 years or
above to be the head of the household for the purpose of issuing of ration
cards.
 Grievance Redressal Mechanism - States have the flexibility to use the
existing machinery or setup separate mechanism.
 Food security allowances - Allowances to the entitled beneficiaries in case
of non-supply of entitled food grains or meals.
Thus, we saw how GOI is making efforts to improve food and nutrition security
situation of the people of India. In Unit 10 later in this course, we will study
about various programmes implemented by GOI to improve food and nutrition
security. Unit 12 and 13 focuses or strategies to combat public nutrition problems in
our country.
In continuation, to improve nutritional security, eradicate poverty and to ensure
environment sustainability, United Nations shaped a broad vision with eight Millennium
Development Goals (MDGs) in year 2000, with a target to achieve these by the year
2015. After the remarkable accomplishment made on many of the MDG targets
worldwide, on 1st January 2016, Sustainable Development Goals (SDGs) have been put
in place. The next section focuses on SDG.
2.9 SUSTAINABLE DEVELOPMENT GOALS

The Sustainable Development Goals (SDGs), otherwise known as the Global Goals, are
a universal call to end poverty, protect the planet and ensure that all people enjoy peace
and prosperity. The SDGs came into effect in January 2016, and they will continue to
guide United Nations Development Programme (UNDP) policy and funding until 2030.
As the lead UN development agency, UNDP is uniquely placed to help in implementation
of the goals. Under this, 17 Goals were laid including new areas such as climate change,
economic inequality, innovation, sustainable consumption, peace and justice, among other
priorities as highlighted in Figure 2.5. These SDGs are universally applied to all countries
and territories.
38 Figure 2.5: The 17 Sustainable Development Goals

Out of these 17 SDGs, 3 goals are of particular importance to us as public nutrition Public Nutrition :
workers. These goals include: Goal 2- Zero hunger, Goal 3-Good health and well being Multidisciplinary
Concept
and Goal 6- Clean water and sanitation.
Each of these goals has set targets under them. These targets are highlighted in Box 2.
Box 2 Targets of Sustainable Development Goals
Targets of Goal 2: Zero Hunger

 By 2030, end hunger and ensure access by all people to have safe, nutritious
and sufficient food all year round
 By 2030, end all forms of malnutrition, including achieving, by 2025, the
internationally agreed targets on stunting and wasting in children under 5 years
of age, and address the nutritional needs of adolescent girls, pregnant and
lactating women and older persons
 By 2030, double the agricultural productivity and incomes of small-scale food
producers, in particular women, indigenous peoples, family farmers, pastoralists
and fishers etc.
 By 2030, ensure sustainable food production systems and implement resilient
agricultural practices that increase productivity and production.
 By 2020, maintain the genetic diversity of seeds, cultivated plants and farmed
and domesticated animals and their related wild species.
Targets of Goal 3: Good Health and Well Being
 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000
live births
 By 2030, end preventable deaths of newborns and children under 5 years of
age, with all countries aiming to reduce neonatal mortality to at least as low as
12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000
live births
 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical
diseases and combat hepatitis, water-borne diseases and other communicable
diseases
 By 2030, reduce by one third premature mortality from non-communicable
diseases through prevention and treatment and promote mental health and well-
being
 Strengthen the prevention and treatment of substance abuse, including narcotic
drug abuse and harmful use of alcohol
 By 2020, halve the number of global deaths and injuries from road traffic accidents
 By 2030, ensure universal access to sexual and reproductive health-care
services,
 Achieve universal health coverage, including financial risk protection, access to
quality essential health-care services and access to safe, effective, quality and
affordable essential medicines and vaccines for all
 By 2030, substantially reduce the number of deaths and illnesses from hazardous
chemicals and air, water and soil pollution and contamination
Targets of Goal 6: Clean Water and Sanitation
 By 2030, achieve universal and equitable access to safe and affordable drinking
water for all
 By 2030, achieve access to adequate and equitable sanitation and hygiene for
all and end open defecation, paying special attention to the needs of women and
girls and those in vulnerable situations
39
Public Nutrition
 By 2030, improve water quality by reducing pollution, eliminating dumping and
minimizing release of hazardous chemicals and materials, halving the proportion
of untreated wastewater and substantially increasing recycling and safe reuse
globally
 By 2030, substantially increase water-use efficiency across all sectors and ensure
sustainable withdrawals and supply of freshwater to address water scarcity and
substantially reduce the number of people suffering from water scarcity
 By 2030, implement integrated water resources management at all levels, including
through transboundary cooperation as appropriate
 By 2020, protect and restore water-related ecosystems, including mountains,
forests, wetlands, rivers, aquifers and lakes
As per the SDG Index, 2018, India ranks 112 out of the total 156 countries, hence still a
long way to go to meet and drive targets.
This brings us to the next section i.e. what do we understand by behaviours related to
food. Let us examine what we mean by food behaviours and the factors which affect
the food behaviours.
2.10 FOOD BEHAVIOUR

Food is merely a means to survival but the fuel that drives the human body and the
economic engine. What influences what we decide to eat when any food is in front
of us? All such actions encompass what is termed as our food related behaviour. Let
us first look at the meaning of word “behaviour”. The word behaviour refers to all the
activities of people singly or collectively. Usually, the word refers to a positive or social
activity. Therefore, from a nutritionist’s point of view, the response of man to food
is termed as food related behaviour or food habits. There are many factors which
affect the food behaviour. These are:
 Physiological and socio psychological factors,
 Cultural factors, and
 Social factors.
Let us examine these factors in detail
 Physiological and socio psychological factors
Food related behaviour depends on a combination of biochemical factors, mainly,

physiological aspects and socio-psychological factors. Hunger and satiety are physiological
functions, which are dependent on the internal stimuli. These two zones of biological
difference are influenced by non-physiological factor called the appetite control. This
factor is dependent on the environment in which man lives and determines the food
practices. The cultural and social values, the economic conditions and educational levels
or other personal factors are reflected in the food practices and habits of its people.
Let us look at the cultural factors next.
 Cultural factors
Food habits vary from one cultural set up to another because each group in its own
evolution sets up a complex pattern of standardized behaviours. Individuals within a
culture respond to the approved behavioural pressures by selecting, consuming and
using those foods that are available. Those food habits and customs, which have
40 become meaningful to the group, are carefully held and not quickly changed. Regional
culture communities are not the only sub cultures of India. For each sub culture, there Public Nutrition :
are a number of religions and caste communities who have their own distinctive Multidisciplinary
cultures. The diets of Hindus in Gujarat and UP may have differences but there are Concept
similarities of ingredients or even taste. Often the diets of Scheduled Castes are
decidedly non-vegetarian as opposed to that of Brahmins and Banyas. Not only are
there differences between the higher and lower castes but also in the same caste with
different social status.
Festivals provide an opportunity of good nutritious food. Even the poor who cannot
afford, consume good foods on such occasions. Abstinence from some kinds of foods
before or during a festival has been practiced throughout the recorded history across
the globe. Many North Indians abstain from animal foods like egg, meat and fish
during Hindu festivals like “Navratas”. The examples present above must have given
you a good idea about the cultural influence on food behaviour. Let us look at the social
factors now:
 Social factors
Sociology of foods and nutrition should have as one of its aims to clarify the manner
in which food becomes a functional element in the social system. Food is often used
to promote an individual or group’s welfare, interpersonal sociability and feeling of
belongingness. Often the place given to nutrition is considerably low than that given
to prestigious items in expenditure. Use of ghee has often played quite a havoc with
the nutritional balance of some people in north India. A pregnant mother among the
north Indian farmers may be given plenty of ghee during her pregnancy. She may be
expected to live on a sweet preparation of ghee, pulse flour and jaggery in rural areas.
Further, it is of specific significance in the Indian population where sequential eating
patterns are observed. Who should be served first in the family? What should be the
priority? The head of the family eats first, then all other men, sons, daughters and
finally the wife and the mother. All the good items in the menu, which are limited, are
given to men of the house and children. Such unequal distribution of meals affects the
availability of food items and thereby nutrients. Another important factor that has had
an influence on the food related behaviours is urbanization. This has led to changes
in family structure, increase in number of smaller household units, increase in the
number and proportion of working women, increase in mobility and ethnic diversity. All
this has influenced food habits of families.
For most of human existence, people’s food supplies consisted only of what nature
placed before them. But in today’s technological society a greater variety of food items
is available than could ever have been imagined. Thus, we conclude that our food
behaviours are shaped not only by productivity and availability but also by social and
cultural influences. All these factors are resulting in a paradigm shift in food related
behaviour. We end our study on food behaviour here. Recall your understanding on the
topic by answering the check your progress exercises given next.

1. Define food and nutrition security. Generate any four factors determining food
security.
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41
Public Nutrition
2. List three factors which affect food behaviour.
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2.11 LET US SUM UP

In this unit we learnt that there are multiple causes of malnutrition and accordingly we
need a multidisciplinary approach to solve nutrition problems.
We learnt how agricultural products including horticultural products, the storage and
distribution of these food items affect the nutrition of people. Then we had a brief
insight about food security and tractors affecting it. You would recalls that food security
is defined a physical and economic access by all people, at all times, to sufficient food
to meet their dietary needs for a productive and healthy life. It is a combination of the
product of four factors: Food availability, food accessibility, utilization and vulnerability.
Inappropriate caring and feeding practices, gender discrimination, unsafe and sanitation
and natural disasters determine food and nutrition security. The response of man to
food is termed as food related behaviour or food habits. There are many factors which
affect the food behaviour. These are: physiological and socio psychological factors,
cultural factors and social factors.
2.12 GLOSSARY
Bunt infection : fungus that destroys kernels of wheat by replacing them with
greasy masses of smelly spores.
Gibberella infection : fungal infection in maize causing rotting of the plant.
Green Revolution : a significant increase in agricultural productivity resulting from
the introduction of high-yielding varieties of grains, the use of
pesticides, and improved management techniques.
Organoleptic : relating to the senses (taste, colour, odour, feel).
Phytochemicals : hundreds of substances produced naturally by plants to protect
themselves from disease. Their exact roles in promoting human
health are still under investigation, but many have antioxidant
activity.

EXCERCISES
1. Multisectoral approach involves organizing activities that would involve teams of
scientists (both social and natural), technologist, policy-makers and planners
(including development economists) and the implementers of programmes to
collectively look into the major problems of mankind and find solutions for them
through co-operative efforts. The concerned disciplines should stimulate each
other consciously and create a comprehensive and dynamic system capable of
multidisciplinary action that could increase the pace of progress towards
establishment of a more equitable and just social order in this world.
2. a. True
42
b. False --- India ranks only second to China in vegetable production, but per Public Nutrition :
Multidisciplinary
capita consumption of vegetables is very low in India. Concept
c. False---Inequitable distribution of available food among different segments of
the population and even within the family is one of the major factors responsible
for undernutrition/overnutrition.
3. Science and technology can help improve food supply by: (a) increasing food
production through better agricultural technology; (b) ensuring effective conservation
and utilization of foods through the application of modern technology.
1. Food security may be defined a physical and economic access by all people, at
all times, to sufficient food to meet their dietary needs for a productive and
healthy life. Nutrition security, on the other hand, refers to a balance between
biological requirements in energy and nutrients and the quantity and quality of
foods consumed. The four main factors which determine food and nutrition security:
These are : Inappropriate caring and feeding practices, gender discrimination,
Unsafe water and sanitation, and Natural disasters.
2. There are many factors which affect the food behaviour. These are physiological
and socio psychological factors, cultural factors, and social factors.
43
Public Nutrition
UNIT 3 NUTRITIONAL PROBLEMS-I
Structure
3.1 Introduction
3.2 Protein Energy Malnutrition (PEM)
3.2.1 Different Forms of PEM
3.2.1.1 Kwashiorkor
3.2.1.2 Marasmus
3.2.1.3 Marasmic Kwashiorkor
3.2.1.4 Sub-clinical PEM
3.2.2 What is the Prevalence of PEM?
3.2.3 What Causes PEM?
3.2.4 What are the Consequences of PEM?
3.2.5 How do we Treat PEM?
3.2.6 How to Prevent and Control PEM ?
3.3 Micronutrient Deficiencies
3.3.1 Vitamin A Deficiency
3.3.2 Iron Deficiency Anaemia
3.3.3 Iodine Deficiency Disorders
3.3.4 Zinc Deficiency
3.4 Let Us Sum Up
3.4 Glossary
3.1 INTRODUCTION
You may recall studying about the macronutrients and micronutrients in Advanced
Nutrition Course (MFN-004). Macronutrients we learnt, are carbohydrates, fats and
proteins and micronutrients are vitamins and minerals. In this unit and the following
Unit we will learn about the deficiency diseases associated with these macronutrients
and micronutrients in the body.
Nutritional deficiencies are widely prevalent in India, particularly in the rural areas
among the poor families. You might have come across in your day-to-day life or read
in popular publications about nutritional disorders occurring due to either deficiency of
macronutrients i.e. energy and proteins or micronutrients like vitamin A and B complex.
Human beings require balanced diet to live, thrive and survive to carry out various
activities. Any imbalance or inadequacy in foods and nutrients could cause ill health;
lead to nutritional disorders and even cause death. This unit focuses on the nutritional
problems of public health consequence.
Objectives
After studying this unit, you should be able to:
l describe the public health significance of PEM, vitamin A deficiency, iron deficiency
anaemia, iodine deficiency disorders and zinc deficiency;
l identify cases of PEM and vitamin A deficiency;
l detect iron deficiency anaemia and iodine deficiency disorders;
l explain the causes and consequences of vitamin A deficiency, iron deficiency
anaemia, iodine deficiency and zinc deficiency;
l provide the treatment of PEM, vitamin A deficiency, iron deficiency anaemia and
44 iodine deficiency disorders;
l describe methods of prevention of vitamin A deficiency, iron deficiency anaemia Nutritional
and Iodine deficiency disorders; and Problems-I
l educate the families and communities on prevention of PEM, vitamin A deficiency,

iron deficiency anaemia and iodine deficiency disorders.
We will first start with the deficiency of macronutrients and then go over to learn
about deficiency of micronutrients. Let us begin with protein energy malnutrition  the
deficiency of macronutrients.
3.2 PROTEIN ENERGY MALNUTRITION (PEM)

Protein Energy Malnutrition (PEM) is the deficiency of macronutrients or energy and
protein in the diet and forms the most important nutritional deficiencies of public health
significance. It is a nutritional disorder, which affects all the segments of population
like children, women and adult males particularly from the backward and downtrodden
communities.
There are many different forms of PEM. Let us learn about these.
3.2.1 Different Forms of PEM
The term PEM is used to describe a wide range of clinical conditions ranging from
the very clinically detectable florid forms to the mildest forms in which growth retardation
is the major manifestation. It is widely prevalent in the developing countries of Asia
and Africa. According to estimates, there are about 200 million children suffering from
various forms of PEM in the world. India contributes almost 40% to the total
malnourished population in the world.
PEM occurs in three clinically distinguishable forms, viz. kwashiorkor, marasmus and
marasmic-kwashiorkor. In addition, a large number of children suffer from various
sub-clinical forms of PEM like underweight, stunting (short stature) and wasting
(thinness). In fact, the proportion of clinical cases of PEM in a given community
reflects only the proverbial “tip of iceberg”. In other words, for every clinical case
there are many more children suffering from sub-clinical PEM. Box 1 lists different
types of PEM.
Box 1 Different types of PEM

Clinical Forms Sub-Clinical Forms
 Kwashiorkor  Underweight
 Marasmus  Wasting
 Marasmic kwashiorkor  Stunting
We will first study about the clinical forms of PEM and then go over to sub-clinical
PEM. Let us start with the first clinical form of PEM i.e. Kwashiorkor.
3.2.1.1 Kwashiorkor
Kwashiorkor is an African word, meaning a “disease of the displaced child”, who is
deprived of adequate nutrition. It is one of the most important florid forms of PEM
occurring mostly in children between the ages of 1 and 3 years, when they are
completely weaned (taken off the breast). The three essential manifestations or signs
of kwashiorkor are:
 Oedema (swelling of feet),
 Growth failure, and
 Mental changes.
45
Public Nutrition In addition, there may be changes in hair and skin associated with infection and
micronutrient deficiencies. Refer to Figure 3.1 which illustrates the clinical forms of
PEM. Frequent infections, particularly diarrhoea and respiratory infections, aggravate
the condition. Most of the children with severe PEM would have recovered from a
recent attack of measles.
Let us review the above clinical signs of kwashiorkor in detail:
l Oedema: Oedema refers to accumulation of fluid in the tissues and usually begins
with a slight swelling in feet gradually spreading up the legs. Later, hands and
face may also have oedema. If oedema is present, a impression is formed when
you apply pressure with your thumb on the lower part of shin or the dorsal part
of foot for about half a minute.
l Poor growth: Growth retardation is the earliest manifestation of kwashiorkor.

The child will be lighter and shorter than its normal peers of same age. The
children with kwashiorkor weigh about 80% or less of their normal peers. This
is usually verified by comparing the body weight of the child with that of normal
children of same age group. Sometimes, in cases of gross swelling, the body
weight may be relatively higher. The child will also be wasted (thinner), which
sometimes could be masked in the presence of extensive swelling of the body.
The child’s arms and legs will appear thin as a result of wasting.
l Mental changes: You would find a kwashiorkor child to be unusually apathetic

with absolutely no interest in the surroundings. The child will also be irritable and
prefers to stay at one place and in one position.
The signs discussed above are essentially present in a child suffering from
kwashiorkor. Other signs which may be present are:
l Hair changes: In kwashiorkor, the hair loses its healthy sheen and becomes
silkier and thinner. It takes coppery red colour (referred to as ‘discoloured hair’).
You could easily pluck small tufts of hair without causing any pain (referred to
as ‘easy pluckability’) just by passing your hands through the hair.
l Skin changes: In many cases, dermatosis (changes in skin) is seen. Such changes
are common in areas of friction. Dark pigmented patches, skin to sun-baked and
blistered paint, are, at times, present (known as ‘flaky-paint dermatosis’). These
desquamated patches may peel off leaving bleeding patches resembling sunburns.
l Moon face: The cheeks may seem swollen with fluid or fatty tissue and often
be slightly sagging. You should not mistake with the chubby cheeks of a normal
and healthy child.
l Micronutrient deficiencies: Almost all the children manifest anaemia (due to

iron deficiency) of some degree. Eye signs of vitamin A deficiency are also
common in more than a quarter of children with kwashiorkor. Manifestations of
vitamin B complex deficiency are also noted in many cases.
l Water and electrolyte: The total body water and especially the extracellular fluid
volume are increased in all forms of PEM. At the same time, there may be
clinical signs of dehydration, particularly sunken eyes, loss of skin turgor, dry
mucosa. As for the electrolytes, its total sodium is increased although in some
cases the serum sodium and osmolarity are seen to be reduced. This is obvious
in patients who have oedema and signs of dehyadration. As for potassium it is
usually deficient and magnesium deficiency is reported.
l Infections: There may be lower respiratory tract infections associated with

diarrhoea/dysentry.
46
Figure 3.1(a) illustrates a kwashiorkor child. Look up Box 2, as well which summarizes Nutritional
the various signs of kwashiorkor. Problems-I
(a) A typical case of kwashiorkor (b) A marasmic child
Figure 3.1: Clinical forms of PEM
Box 2 Signs of Kwashiorkor

l Oedema
l Underweight (<80% of normal weight for age)
l Apathy and irritability
l Moon face
l Hair and skin changes
l Micronutrient deficiencies
Let us now move on to the next clinical form of PEM i.e. marasmus
3.2.1.2 Marasmus
Marasmus, the other end of the same spectrum as kwashiorkor, is common in children
below the age of 2 years. The characteristic manifestations, as illustrated in Figure
3.1(b) are:
l Severe growth retardation
l Extreme emaciation
l Old man’s or monkey’s face, and
l Loose and hanging skin folds over arms and buttocks.
As you may have noticed in Figure 3.1(b), a typical case of marasmus can be
described as a bonny cage having nothing but “skin and bones”. You would notice that 47
Public Nutrition the marasmic children are so weak that they may not have even energy to cry, which
most often is barely audible. The child is extremely wasted with very little subcutaneous
fat with the skin hanging loosely particularly over the buttocks. In fact, when you hold
the marasmic child in a standing position, you can see the loose skin folds hanging
prominently, unlike in any normal child. For the given age, the children will be generally
below 60% normal or < Median - 3SD of the standards. We will learn about these
standards later in this unit. Unlike in kwashiorkor, oedema is absent and there are no
skin and hair changes. However, frequent diarrhoeal episodes leading to dehydration
and micronutrient deficiencies of vitamin A, iron and B-complex are common. Box 3
lists the signs and symptoms of marasmus.
Box 3 Signs and symptoms of Marasmus
 Extreme muscle wasting - “skin and bones”
 Loose and hanging skin folds
 Old man’s or monkey face
 Absolute weakness
Let us now move on to the third clinical form of PEM-Marasmic kwashiorkor.
3.2.1.3 Marasmic Kwashiorkor
Sometimes, in areas where PEM is common, malnourished children exhibit the features
of both kwashiorkor and marasmus. Such changes could occur during the transition
from one form of severe PEM to another. For example, a marasmic child can develop
oedema after a severe bout of infection or a kwashiorkor child, when loses oedema
may develop this condition. Such a child is considered as suffering from ‘marasmic
kwashiorkor’. These children will have extreme wasting of different degrees (representing
marasmus) and also oedema (a sign of kwashiorkor). They may also manifest some
hair changes and often diarrhoea. Box 4 lists the signs and symptoms of marasmic
kwashiorkor. So, it must be evident that there is a continuous spectrum of signs from
oedematous kwashiorkor through varying degree of marasmus associated with
oedema. For your reference we have included the main features of PEM in children
in Table 3.1.
Look up Box 4 for the signs of Marasmic Kwashiorkor.
Box 4 Signs and Symptoms of Marasmic Kwashiorkor
l Extreme muscle wasting - “skin and bones”
l Loose and hanging skin folds
l Old man’s or monkey’s face
l Absolute weakness
l Oedema
Besides the specific and essential features discussed above a number of biochemical
changes have been described in the blood, urine, gastrointestinal secretions, endocrine
functions and tissue composition in PEM. The changes that are most important in
48 diagnosis and treatment are summarized in Table 3.2.
Table 3.1: Features of PEM in children Nutritional
Problems-I
Features Marasmus Kwashiorkor
Essential Features
1. Oedema None* Lower legs,
sometimes face, or
generalized
2. Wasting Gross loss of sub Less obvious;
cutaneous fat, “all skin sometimes fat,
and bones”* blubbery
3. Muscle wasting Severe* Sometimes
4. Growth retardation in terms Severe* Less than as in
of body weight case of Marasmus
5. Mental changes Usually none Usually present
Variable features
1. Appetite Usually good Usually poor
2. Diarrhoea Often (past or present) Often (past or
present)
3. Skin changes Usually none Often, diffuse
pigmentation;
occasional “flaky-
paint”* or “enamel”
dermatosis
4. Hair changes Texture may be Often sparse-
modified but no straight and silky;
dyspigmentation dyspigmentation
grayish or reddish
5. Moon face None Often
6. Hepatic enlargement None Frequent, although it
is not observed in
some areas.
*The most characteristics or useful distinguishing features.

Table 3.2: Biochemical signs specific to PEM
Biochemical Changes Marasmus Kwashiorkor
Serum albumin Normal or slightly decreased Low*
Urinary urea per g of Normal or decreased Low*
the creatinine
Urinary Hydroxyproline Index Low Low*
Serum free amino acid ratio Normal Elevated*
Anaemia May be observed Common iron
and folate
deficiency may
be associated
Pancreatic secretions Reduced enzymatic activity Reduced
enzymatic
activity
* The most characteristic or useful distingushing features 49
Public Nutrition As you may have noticed in Table 3.2, serum albumin and also serum total protein are
markedly decreased in kwashiorkor. It is important to note that serum albumin level is
one of the most useful biochemical indicators of PEM. We will learn more about this
biochemical indicator later in Unit 9. As for the changes in urine, the hydroxyproline
excretions in urine, is proposed as an indicator of the rate of growth in children with
PEM. The index is essentially constant between the age of 6 months and about 5
years. It is low in malnourished children. Further, the urinary excretion of creatinine
decreases in relation to the reduction in the muscle mass. Hence, in both kwashiorkor
and marasmus the creatinine excretion is low.
We have learnt about clinical forms of PEM. Now let us learn about sub-clinical PEM.
3.2.1.4 Sub-clinical PEM
You have already learnt that clinical forms of PEM represent only a small proportion
of the total cases of PEM in a community in rural India. Growth retardation is not only
an important and objective manifestation of PEM, but is also the first response to
rehabilitation in such cases. Anthropometry (body measurement) is extensively used
to detect various degrees of sub-clinical forms of PEM. Body weight is, by far, the
most sensitive and frequently used parameter of nutritional status particularly in preschool
children (1-5 years). Several methods have been suggested for classification of PEM
in children based either on body weight alone or in combination with standing height/
recumbent length.
The following classifications based on body weight are commonly used in India.
1. WHO classification.
2. Indian Academy of Paediatrics (IAP) classification.
A detailed discussion on these specifications is presented in Unit 7. Here a brief review

is presented.
1) WHO Classification
For population - based assessment the Z-Score (or standard deviation classification) system
is widely used. The Z-Score system expresses the anthropometric value as a number of
standard deviation or Z-Score below or above the reference mean or medium value.
Table 3.3 presents the classification and categorization of children into various degree
of undernutrition based on mean/median and SD.
Table 3.3: WHO classification for weight-for-age
Weight-for-Age Criterion Grade of Undernutrition
>Median 2SD Normal
<Median 2SD to Median3SD Moderate
<Median 3SD Severe
The WHO Global Database on Child Growth and Malnutrition used a Z-Score cut-off
point < -2SD to define moderate undernutrition and <-3SD as severe undernutrition. Cut-
off point of >+2SD classified as overweight in children.
Severe Acute Malnutrition (SAM) is the severest form of undernutrition and may
result from inadequate recent food intake or illness and mainly manifests as ‘wasting’.
50 WHO defines Severe Acute Malnutrition (SAM) in children as weight-for-height
below 3 Standard Deviation (SD) and mid-arm circumference less than 115 mm or by Nutritional
presence of nutritional oedema. Diagnostic criteria for SAM in children aged 6 – 60 Problems-I
months are given in Table 3.4.
Table 3.4: Diagnostic criteria for SAM in children aged 6 – 60 months

Indicator Measure Cut-off
Severe wasting Weight  for  height Less than 3SD
Severe wasting MUAC Less than 115 mm
Bilateral oedema Clinical sign
Source: UNICEF-WHO-The World Bank: Joint child malnutrition estimates - Levels and trends,
2012
2) Indian Academy of Paediatrics (IAP) Classification
In India, the classification of children, which is extensively used to group children into
various grades of malnutrition is the one proposed by the Indian Academy of Paediatrics.
Growth charts based on this classification are used in the largest national nutrition
intervention programme, Integrated Child Development Services (ICDS), for growth
monitoring of children. The nutrition sub-committee of IAP considered that children
with body weights more than 80% of standards should be as normal and suggested the
classification given in Table 3.5.
Table 3.5: IAP classification for weight-for-age (1972)
Weight-for-age of the Grade of Severity
Standard (% median) Undernutrition
>80 --- Normal
70-79.9 I Mild Undernutrition
60-69.9 II Modeate Undernutrition
50-59.9 III Severe Undernutrition
<50 IV Very Severe Undernutrition
The extent of a disease is measured in terms of prevalence rate, which indicates the
number of individuals with a particular disease (numerator) at a particular point
of time in a specified number which is usually per 100 population of a community
(denominator). The prevalence of kwashiorkor and marasmus, which was about 4%
in the early sixties, has declined substantially over the period. As per National Family
Health Survey NFHS-4 (2015-16) data, 35.7% children under 5 years of age are
underweight (low weight-for-age), 38.4% are stunted (low height-for-age) and
21% are wasted (low weight-for-height), with 7.5% severally wasted. Thus, the
problem of PEM in India is widespread and requires immediate intervention.
Since, the problem of PEM in India is widespread and requires immediate intervention,
next thing which must be coming to your mind is what causes it. Let us now learn what
are its causes.
51
Public Nutrition 3.2.3 What Causes PEM?
Some of the causes of PEM are elaborated herewith:
Low Birth Weight
The beginning of PEM in children starts in rural India from the time of their birth. At
least one third of the Indian children are born with low birth weights (less than 2.5 kg)
due to high maternal malnutrition (malnutrition in mother).
Inadequate Breast Milk
Though prolonged breastfeeding of children is the rule in rural India, the amount of
breast milk secreted in poor Indian mothers is lower than either normal women or
those from developed countries. In other words, the infants may not be consuming
adequate breast milk leading to inadequate nutrition.
Delayed Complementary Feeding (Faulty Infant Feeding Practices)
The mothers from poorer socioeconomic groups where PEM is more prevalent, delayed
introduction of complementary foods (foods in addition to breast milk) usually until the
infant completes one year of age is a common practice. Thus, when breast milk is not
adequate, delaying complementary feeding further aggravates the dietary inadequacy
among such infants leading to PEM. Rural Indian women, due to ignorance, firmly
believe that children should be given complementary foods only when they are able to
pick and eat. After weaning (completely stopping breastfeeding), the children are not
given any special diet other than the adult diet. Young infants cannot consume these
diets in adequate amounts due to its bulk. Early and abrupt weaning and introduction
of diluted milk formulae is one of the reasons for marasmus.
Primarily Energy Deficiency
Surveys on preschool children in different parts of the country reveal that PEM is
primarily due to dietary energy deficiency arising as a result of insufficient food intake.
The primary bottleneck in the dietaries of Indian children, who are given cereal-pulse
based diets, is energy and not protein as, hitherto was believed.
Infections and Infestations
Childhood infections (viral/bacterial) and parasitic infestations are almost always

associated with PEM. These cause anorexia (loss of appetite) leading to reduced food
intake, interfere with nutrient absorption and utilization, and result in nutrient losses.
The role of measles infection, frequent diarrhoea and acute respiratory infections in the
onset of PEM is very important.
Ignorance and Poor Socioeconomic Status
Improper childcare, either as a result of lack of knowledge or lack of time for mother,
could also contribute to the onset of PEM. PEM is mainly a disease of the poor and
downtrodden. The mothers in these families are illiterate, work for their living and are
largely influenced by the belief systems of the society, are superstitious and believe in
spiritual healing etc. The families are generally large, and even if they spend their
complete income on food with low purchasing power they would be unable to meet
52 the requirements. Box 5 highlights causes of PEM.
Nutritional
Box 5 Causes of PEM Problems-I
 Maternal malnutrition  Low purchasing power
 Low birth weight  Food taboos and superstition
 Faulty child feeding practices  Large families
 Dietary inadequacy  High female illiteracy
 Frequent infections
We have seen that PEM is a nutritional disorder of public health significance. Let us
now study what happens if PEM is not prevented and or treated. In other words, let
us learn about the consequences of PEM.
3.2.4 What are the Consequences of PEM?

The consequences of PEM are most often long lasting and irreversible. The common
consequences include:
l Irreversible growth retardation
l Increased susceptibility to infections
l Increased risk of mortality
l Low cognitive performance
As a result of extensive PEM since early childhood, in India, there is irreversible
growth retardation leading to short stature among adults. While children of well to do
communities, where the problems of inadequate diet and ill health are not common, are
as tall and heavy as those from developed countries, poorer children suffer from
stunting, wasting and underweight. Studies in different parts of India revealed that in
children suffering from various grades of PEM, their immunity (ability to fight infections)
is reduced and as a result, the incidence of childhood infections like diarrhoea and
respiratory infections is high. The children with severe forms of PEM are usually
brought to the hospital with complications arising as a result of severe infections. The
immunity in these children are low leading to lowered resistance to infections. Therefore,
respiratory and gastrointestinal infections are not only common but their severity is also
higher. Severe diarrhoea might lead to dehydration. Septicemia and bronchopneumonia
in children with kwashiorkor and marasmus could be fatal. It should also be recognized
that such infections could increase the risk of PEM leading to a vicious cycle of
malnutrition and infection. The risk of mortality in moderate and severe PEM is higher,
particularly when they are exposed to frequent infections. The work output of adults
who are lighter also has been shown to be lower affecting the productivity of the
nation.
We have learnt about the causes and consequences of PEM. Next, let us learn how
we can treat PEM.
3.2.5 How do We Treat PEM?

Major objective of the treatment of PEM is to provide adequate energy and protein
intake and control infections, if any. Mild and moderate forms of PEM can be and
should be managed at home under the supervision of health professional. Severe forms
of PEM should be referred to a hospital particularly when associated with severe
bronchopneumonia and diarrhoea. All the cases without any complications can be
managed as outpatients in either a primary health centre or a hospital. Here we will
study the treatment of severe PEM. The key components of treatment are: 53
Public Nutrition l Diet
Treatment of cases of kwashiorkor or marasmus involves mainly providing appropriate

nutrition support. The child should receive a diet that provides adequate amounts of
energy and protein. Both of these are required in larger quantities than normal
requirements for rapid recovery. The child should be given the following concentrations:
Energy : 170-200 kcal per kg of body weight
Protein : 3-4 g/kg of body weight
Initially, milk based liquid diet, using either fresh milk or dry skimmed milk powder, is
recommended. A milk formula could be prepared in one litre of clean water by adding
dried skimmed milk powder: 90 g, sugar: 70 g and vegetable oil: 50 g. About 100 ml
of reconstituted preparation would provide 100 kcal and 3 g of protein. The formula
should be given to the children at the rate of 100-150 ml per kg of body weight. As
dried skimmed milk powder does not contain any vitamin A, it should be enriched with
vitamin A. Sugar or vegetable oil can be added to increase the energy content.
In the beginning, the child may refuse to accept any feeds due to loss of appetite.
Under such situations, the diet could be given with a spoon. In extreme cases, gastric
intubation (feeding through tube) may be resorted to. With improvement in appetite, the
child would start eating the diet readily, at which time gradually solid foods can be
introduced. In older children special diet based on cereal, pulse, dried skim milk
powder and sugar/jaggery can be given. Addition of vegetable oil would increase the
energy density of the recipe.
l Vitamin and mineral supplements
All cases of severe PEM require multivitamin preparation to meet the increased
demands during recovery. Iron (60 mg) and folic acid (100 mcg) may be given daily
to correct anaemia.
l Oral rehydration
Since diarrhoea is very common in severe PEM, correction of dehydration is the first
step in the treatment. Home made (salt-sugar mixture) or commercial oral rehydration
solution (ORS) can be administered to correct dehydration. The WHO recommends
that the ORS formula should contain: Sodium Chloride 2.6 g, Glucose Anhydrous
13.5 g, Potassium Chloride 1.5 g and Trisodium Citrate 2.9 g. It should be dissolved
in a litre of clean water and given to the child in small quantities at frequent intervals
at the rate of 70-100 ml/kg body weight. Intravenous fluids are required only in severe
dehydration. This new ORS formula with reduced osmolarity is more advantageous in
treating child with acute diarrhoea.
l Control of infections and infestations
Appropriate antibiotics should be started immediately since infections are the immediate
cause of death in many children. Children with intestinal infestations like giardiasis and
ascariasis should be treated.
l Clinical progress
Normally, clinical improvement is evident within a week with the disappearance of
oedema. The appetite improves almost dramatically and the child starts gaining weight,
after initial loss of body weight. The mother should be advised about the diet precisely.
It would be better to involve her in the preparation of suitable recipes during the child’s
stay at the hospital.
We have learnt so far about the treatment of a child suffering from PEM. Have you
heard the old proverb - ‘‘prevention is better than cure’’. So, it becomes extremely
important that we make sincere efforts to prevent and control, PEM. Let us now see
how this could be done.
54
3.2.6 How to Prevent and Control PEM ? Nutritional
Problems-I
Any programme aimed at prevention of PEM should be holistic and comprehensive
considering the family as a unit. Since the effects of undernutrition are
cummulative, currently it is being emphasized that ‘life cycle approach’ as illustrated
in Figure 3.2 should be adopted.
Adolescence Pregnancy Lactation
School age Preschool childhood Infancy
Figure 3.2: Life cycle approach
It is generally recommended that the entry point into the life cycle is the adolescent
girl, who will be the future mother and should be given adequate attention. Their
nutrition should be ensured and the family should be educated against the practices
like adolescent marriages and pregnancies so that they would be prepared to be
healthy women of tomorrow to be able to handle pregnancy, lactation and child care
effectively. At all levels, the advice should include both health care and nutrition.
Given below are some of the measures which should help in prevention of PEM.
l Ensure proper diet
PEM is preventable. It is a disease of the poor and the ignorant that suffer from
social inequalities. Therefore, a holistic approach is necessary to prevent and control
PEM. The most critical aspect is to ensure that the child is fed adequate quantities
of diet containing all the nutrients daily. Therefore, the communities should be made
aware that it is in their hands to ensure that their children and other members of
the family consume adequate diets daily.
l Increase purchasing power
The Government of India formulated the National Nutrition Policy and prepared
National Plan of Action to bring down the prevalence of moderate and severe
malnutrition. We will study about the National Nutrition Policy later in Unit 10. Here
we should know that along with direct nutrition intervention, socioeconomic
development, aimed at poverty alleviation to increase the purchasing power of the
rural and urban poor, should become an important component of control programme.
The essential components of any control programme are: supplementary feeding,
immunization, control of minor infections, promoting food security, nutrition
communication, poverty alleviation, and empowerment of women. These components
are described in detail later in Unit 12 and 13 in this course. However a brief review
is presented herewith.
l Supplementary feeding
Supplementary feeding has remained an important component to control undernutrition.
Considering the dietary inadequacy in the diets of poor rural families, various
programmes provide daily supplementary food providing about 500 calories of energy
and 12-15 g of protein per child under various feeding programmes. Of the direct
intervention programmes of the government, Integrated Child Development Services
(ICDS) is the largest being implemented by the Department of Women and Child
Welfare of the Government of India in over 4000 projects all over the country with
emphasis on backward and tribal areas. Supplementary feeding is an important
component of ICDS. Other components are immunization, growth monitoring, and
treatment of minor illness, non-formal preschool education, and nutrition education to
the mothers. The Department of Health ensures immunization of children, distribution
of six monthly massive doses of vitamin A and iron and folic acid tablets and
treatment of minor ailments. 55
Public Nutrition l Promoting food security
Public distribution of food grains through a network of ration shops, particularly to

reach the population below the poverty line, so as to improve availability, access to
food grains at affordable prices is an important step to improve food and nutrition
security of the poor.
l Poverty alleviation
There are a number of development programmes aiming at employment assurance to

the landless and other labour, with a focus on increasing the purchasing power. We will
study about these programmes later in Unit 10, Section 10.8.
l Behavioural change communication
One of the reasons for the widespread prevalence of PEM in our country is
ignorance due to illiteracy, particularly among the females. Therefore, there is a need
to change the behaviour in these women through effective communication programmes.
Person-to-person communication, cooking demonstrations, and mass media like
television and radio are some of the tools that are available. We should convince the
community, particularly the mothers about the need for proper diet to children for
normal growth and to prevent them developing PEM. She should be made aware
that the main reason for PEM is shortage of food either as a result of poverty or
due to inequitable intrafamily distribution of foods. You should be equipped to give
advice on complementary feeding and be able to inform the mothers as to the types
of foods that could be given to young children. Box 6 highlights essential components
of prevention of PEM.
Box 6 Essential Components to Prevent PEM
 Supplementary feeding
 Immunization
 Control of minor infections
 Promotion of food and nutrition security
 Behaviour change communication
 Empowerment of women and
 Poverty alleviation
Eradication of PEM requires concerted efforts not only on the part of the government
but also continuous and active community participation. Integration, convergence,
commitment and community participation are the crucial pillars of any prevention
strategy.
In this section, we learnt about signs, causes, prevalence, treatment and prevention of
PEM. In the next section, we will discuss the micronutrient deficiencies. But before
that, let us recapitulate what we have learnt so far. Answer the questions given in the
check your progress exercise 1.
1. What are the different clinical forms of PEM?
..........................................................................................................................
56 ..........................................................................................................................
Nutritional
2. Record in the format below differences between kwashiorkor and karasmus. Problems-I
Manifestations Kwashiorkor Marasmus
3. What are the different classifications used to detect sub-clinical forms of PEM?
...........................................................................................................................
...........................................................................................................................
4. Indicate the criteria used for the following classifications based on weight for age.
Grade of PEM Indian Academy of Paediatrics
Normal
I
II
III
IV
5. What are the main principles in the treatment of severe PEM?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
6. What steps do you recommend to prevent and control PEM?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
3.3 MICRONUTRIENT DEFICIENCIES

In the previous section, we learnt about macronutrient deficiencies i.e. protein energy
malnutrition in children. We are now aware that this is an important problem of public
health significance affecting millions of young Indian children belonging to poverty stricken
rural communities. In addition to this, deficiencies of specific micronutrients like vitamin
A, iron and iodine affect large/segments of population. We have studied earlier that
micronutrients are nutrients which, although required in minute quantities, are essential
to maintain the normal metabolism and function. Some people also call them ‘super
nutrients’, indicating their importance and also signifying the dreaded ill effects of their
deficiencies in the communities. Of all the micronutrient deficiencies, those of vitamin A,
iron and iodine affect millions of populations and contribute to high morbidity and mortality.
Apart from these, deficiencies of micronutrients such as zinc, selenium and molybdenum,
though do not manifest as overt problems, can lead to functional changes. Box 7 lists
common micronutrient deficiencies. 57
Public Nutrition
Box 7 Common Micronutrient Deficiencies
 Vitamin A deficiency
 Iron deficiency anaemia
 Iodine deficiency disorders
 Zinc deficiency
We will now discuss these micronutrient deficiencies in detail. Let us begin with
Vitamin A deficiency.
3.3.1 Vitamin A Deficiency

Vitamin A deficiency (VAD) is a major public health problem, and the most vulnerable
are preschool children and pregnant women in low income countries. In children, VAD
is the leading cause of preventable severe visual impairment and blindness. An estimated
250,000 to 500,000 VAD children become blind every year worldwide, and about half
of them die within a year.
Vitamin A, we know, is essential for maintenance of healthy epithelium and normal
vision. Deficiency of vitamin ‘A’ manifests in the form of eye lesions, which are
grouped under ‘xerophthalmia’, can be either mild leading to night blindness and changes
in conjunctiva (white of the eye) or in severe form causing damage to cornea (black
of the eye) leading to irreversible blindness. We will learn about these ocular
manifestations, prevalence, causes, treatment and prevention of vitamin A deficiency
in thise section.
Let us begin with the signs and symptoms of vitamin A deficiency.
Clinical Features of Vitamin A Deficiency
The clinical features or the ocular manifestations specific to vitamin A deficiency are
described herewith and illustrated in Figure 3.3.
(a) Bitot Spot (b) Bitot Spot with the xerosis of conjunctiva
(c) Keratomalacia
58 Figure 3.3: Clinical manifestations of xerophthalmia
Night Blindness Nutritional
Problems-I
Night blindness is the earliest symptom of Vitamin ‘A’ deficiency. You may recall
studying in the Nutritional Biochemistry Course (MFN-002) and the Advance Nutrition
Course (MFN-004) that reduction in the supply of vitamin A aldehyde i.e. retinal to the
rod cells of the retina results in of dark adaptation. Under such situations, the affected
child due to the impairment cannot see properly in sunlight particularly after the sunset.
Often, an attentive mother can recognize the child’s inability to see the plate of food
or toys in ill-lit room.
Pregnant women often experience deficiency symptoms, such as night blindness, that
continues into the early period of lactation. In most part of the country, there is a local
term for the condition, example in Hindi, it is called as “Rathaundi ”.
Bitot’s Spots
As the deficiency progresses, dirty white, foamy and raised spots are formed on the
surface of the conjunctiva, generally on the outer side of the cornea as you may
observe in Figure 3.3(a). These spots are accumulation of denuded conjunctival epithelial
cells. They stain black in the eyes when applied ‘Kajal’. You would notice that the spot
is quite superficial and more or less readly removed by direct inking or by lacrimination
in a crying.
Conjunctival Xerosis
Conjunctiva in normal children is bright white, smooth and glistening. Conjunctival
xerosis is characterized by dryness of the conjunctiva, after exposure to air for 10-15
seconds by keeping eyelids drawn back, which also becomes thick, rough and wrinkled.
In case of an affected child, the changes associated with conjunctiva include: dryness
(the literal meaning of ‘‘Xerosis’’), unwettability, loss of transparency, wrinkling and
pigmentation. Refer to Figure 3.3(b) which illustrates the conjunctival xerosis along
with bitot spot.
Corneal Xerosis
This is a sign of severe vitamin ‘A’ deficiency, in which the cornea loses its normal
smooth and glistening appearance and becomes dry and rough. The child tends to
keep the eyes closed, particularly in bright light due to photophobia (inability to see in
bright sun) and hence, the condition may be missed during the clinical examination, if
not observant.
Corneal Ulcer
Corneal xerosis, if not treated promptly, leads to ulceration of the cornea. Initially, the
ulcer may be shallow, and if it becomes deep, it may lead to perforation resulting in
prolapse of contents of the eyeball. These lessions are more common in the lower
central cornea.
Keratomalacia
This is a condition of rapid destruction and liquefaction of full thickness of cornea,
leading to prolapse of iris, resulting in permanent blindness. Usually keratomalacia
consists of characteristic softening of the entire thickness of a part, or more often
the whole of the cornea leading to deformation or destruction of the eyeball. It is
painless but the corneal structure just melts into a cloudy gelatinous mass, dead-white
or dirty yellow in colour. Extrusion of the lens and loss of the vitreous may occur. In
infective conditions, the eye will be red and swollen. Figure 3.3(c) illustrates
keratomalacia.
Corneal Scar
The corneal ulcer, on healing, leaves a white scar, which may vary in size depending
upon the size of the ulcer. When the scar is big or positioned centrally blocking the
pupillary region, normal vision is affected. 59
Public Nutrition In addition, to the above mentioned manifestations, thickening of the hair follicles
(follicular hyperkeratosis) is a cutaneous manifestation of vitamin A deficiency.
From the description above it must be clear that xerophthalmia represents the ocular
consequences of vitamin A deficiency that includes various manifestations, about which
we have learnt above and the same are classified by WHO as given in Table 3.6.
Table 3.6: WHO classification for assessment of vitamin A status
Classification Primary Signs
XI A Conjunctival Xerosis
XI B Bitot’s Spots
X2 Corneal Xerosis
X 3A Corneal Ulceration
X 3B Keratomalacia
Secondary Signs
XN Night blindness
XF Fundal changes
XS Corneal scarring
The classification presented above may be summarized as:

l Stage XN is the earliest stage, involving night blindness owing to impaired dark
adaptation,
l Stage XI A is corneal xerosis caused by reduction of goblet cell mucous,
l The appearance of Bitot’s spot, a foamy excrescence on the temporal surface of
the conjunctiva, constitutes the advancing stages (XIB),
l X2 consists of simple drying of the cornea,
l When the cornea undergoes the liquification process of keratomalacia, corneal
ulceration, or both, it is classified as X3,
l The situation is classified as X3A if <1/3 of the corneal surface is involved,
l Past involvement leaves a corneal scar (XS), and
l A globe destroyed by advanced keratomalacia is xerophthalmic fundus (XF).
The discussion above focused on the signs and symptoms of Vitamin A deficiency. Let
us now learn how common the problem of vitamin A deficiency is i.e. the prevalence
of vitamin A in our country.
Prevalence of Vitamin A deficiency

The World Health Organization (WHO) has recommended a set of prevalence criteria
(both clinical and biochemical) for defining the vitamin A deficiency (VAD) problem
of public health significance among children under 6 years of age in the community.
This criteria is given in Table 3.7. The prevalence of any one or more indicators
60 signifies public health problem.
Table 3.7: Prevalence criteria for defining the vitamin A deficiency Nutritional
problem of public health significance among children under 6 years of age Problems-I
Indicator/Criteria Minimum Prevalence (%)

Clinical
Night Blindness (XN)* >1.0
Bitot’s spot (X1B) >0.5
Conjunctival xerosis with Bitot’s spot (XI) >0.5
Corneal xerosis/ulceration/keratomalacia
(X2, X3A, X3B) >0.01
Xerophthalmia related Corneal scars (XS) >0.05
Biochemical
Serum retinol (vitamin A) >5.0
< 0.35 µmol/l (<10 µg/dl)**
* Proposed prevalence of night blindness in pregnant women >5% (IVACG, 2001)

** Proposed to be > 15% with serum retinol < 7.0 µmol/l (IVACG, 2001)
Source: WHO, 2014.
Surveys by National Nutrition Monitoring Bureau (NNMB) and the Indian Council of
Medical Research (ICMR) in 2001 revealed, that about 0.7% of preschool children
have bitot spots and prevelence of night blindness is less than 0.5%. As you would
note from the Table 3.4, that as per WHO, prevalence of bitot spots more than 0.5%
in children under the age of 6 years is an indication that vitamin A deficiency is a
public health problem requiring intervention. During the last two decades, the extent
of bitot spots in children showed a decline from about 2% to about 0.7%. The
contribution of vitamin A deficiecy to total blindness has come down significantly
during the last 4 decades.
It is estimated that globally about 30% of children <5 years of age are vitamin A
deficient, and about 2% of all deaths are attributable to VAD in this age group. But
gradually the figure has declined; data suggests that in 1991, 39% of children aged 6-
59 months in low-income and middle-income countries were vitamin A deficient, which
significantly reduced to 29% in 2013, with high prevalence in Sub-Saharan Africa
(48%) and South Asia (44%) (Lancet Global Health, 2015).
We have learnt about the signs and symptoms and the criteria for assessing the public
health significance of xerophthalmia and vitamin A deficiency. Next, you must be
wondering what is its etiology? Let us find out.
Causes of vitamin A deficiency
Some of the causes of vitamin A deficiency are given below:
l Inadequate diet
An Indian child is born with poor stores of vitamins and minerals due to maternal
malnutrition. Diets of pregnant women are deficient in several nutrients, including
vitamin A. The concentration of vitamin A in breast milk is low among undernourished
mothers and the most poor mothers delay complementary feeding beyond the age of
one year and foods containing vitamin A are seldom given. The daily intake of vitamin
A is about 100 mg while the recommended intake is 900 mcg RAE. The exclusively
vegetable based diets, therefore, contain -carotene and little or none of preformed
vitamin A, except from breast milk.
61
Public Nutrition l Poverty and ignorance
Low purchasing power of the communities and their consequent inability to meet the
nutrient requirements and traditional wrong beliefs and ignorance are also important
causes. Low cost -carotene and iron rich foods like dark green leafy vegetables and
fruits like papaya are not given to children and pregnant women due to the belief that
consumption of green leafy vegetables leads to diarrhoea in children and papaya when
consumed by pregnant women can cause abortions.
l Infections
During acute infections, vitamin A intake in preschool children is reduced due to
impaired appetite and impaired vitamin A absorption as in acute diarrhoea and respiratory
infection, and, consequently, serum levels of vitamin A are significantly reduced during
acute infections. An infective episode of diarrhoea and respiratory infection and an
attack of measles can aggravate vitamin A deficiency. Vitamin A deficiency is often
associated with ascariasis and giardiasis.
You learnt about the causes of vitamin A deficiency. Let us now look at how we can
treat vitamin A deficiency.
Treatment of vitamin A deficiency
All forms of vitamin A deficiency are treated with a massive oral dose of vitamin A
in oil (200,000 IU), immediately after diagnosis. The health workers may refer all
cases of corneal xerophthalmia, after first administering vitamin A, to medical doctor.
Secondary infections should be controlled with suitable antibiotics. If necessary, a
second dose may be given 48 hours after the first dose. Since more than 90% of the
cases of keratomalacia are associated with severe clinical protein energy malnutrition
(kwashiorkor or marasmus), the patients should also be treated for the same. A
schedule recommended by WHO for treatment of individuals with corneal xerophthalmia
is given in Table 3.8.
Table 3.8: Treatment of xeropthalmia in all ages
Timing of Dose Children Children Children over 12

(0-5 months) (6-12 months) Months, Male
Adolescent and
Male Adults
Immediately on diagnosis 50 000 IU 100 000 IU 200 000 IU
The following day 50 000 IU 100 000 IU 200 000 IU
Subsequent contact 50 000 IU 100 000 IU 200 000 IU

(at least 2 weeks later)
In women of reproductive age group with night blindness or bitot spots, a daily dose
of 10 000 IU or a weekly dose of 25 000 IU of vitamin A for at least 4 weeks is the
recommended treatment schedule. In population with a high prevalence of HIV infection
(>10%), neonates should be given an extra dose of 50 000 IU at birth.
We have learnt that vitamin A deficiency is a condition of public health significance.

Let us now understand what we can do to prevent vitamin A deficiency.
Prevention of vitamin A deficiency?

Since dietary inadequacy is the major cause for micronutrient deficiencies, the most
rational approach to prevent these deficiencies would be to ensure adequate amounts
of the nutrients in the daily diets of the population at risk. There are two basic
62 approaches to achieve this: i) long term programmes for promotion of adequate intakes
of foods rich in micronutrients, and ii) supplementation of specific nutrients either as Nutritional
medicinal doses or through food fortification to meet immediate needs. In view of the Problems-I
serious nature of the problems, many countries have been adopting short-term measures,
which though are interim in nature. Some of these measures by which we could
prevent vitamin A deficiency are highlighted next.
Supplementation
Administration of large doses of vitamin A to children at risk has been the most popular
approach to control nutritional blindness. Extensive field trials carried out by NIN,
Hyderabad have demonstrated the feasibility and effectiveness of this approach. The
Government of India has launched vitamin A supplementation programme (VAS) on a
national scale, as early as in 1970. The programme is now in operation in all the states
of the country, targeted to about 30 million preschool children. Under this programme,
sponsored by the Department of Health and Family Welfare, Government of India, one
teaspoonful of oil-miscible vitamin A syrup containing 200,000 IU of vitamin A is given
once every 6 months to children between the ages of 6-59 months. The programme
is implemented through the sub-centre — primary health centre complex of the States.
Paramedical personnel (ANM/MPHW), under the supervision of the PHC Medical
Officer, carry out the actual distribution of vitamin A supplements.
Food Based Approach

Although, nutrient supplementation is a simple and effective intervention, it is only a
short-term measure. It must be combined with dietary intervention or food based
approaches for long lasting effects. What are these food based approaches? A detail
discussion on this approach is presented later in Unit 12 in this course. Here in the
context of vitamin A deficiency, fortification as a food based strategy has been used.
Fortification of sugar has been in operation in Central American countries with reasonable
success. In India, sugar may not be the suitable vehicle for the most needy segments
of population who are very poor and cannot afford the same. Home gardening, another
food based approach, has been found to be a feasible long-term strategy, to increase
production and consumption of leafy and other vegetables and fruits by the community
to control vitamin A deficiency. The Departments of Agriculture and Social Forestry
are making efforts in this direction. The Indian Council of Agricultural Research
(ICAR) has established 694 Krishi Vigyan Kendras (KVK's) or Farm Science Centres
so far in various parts of the country to impart training in agriculture technologies to
farmers. In the past, the major thrust was on cereal and millet production. It is only
in the recent years that horticulture production is receiving emphasis. Women Extension
Workers are trained not only in agriculture technologies, but also in home gardening
and preparation of recipes based on locally available nutritious foods.
Nutrition Education
Ignorance, you may recall studying earlier, is an important determinant of vitamin A
deficiency. There is, therefore, a need to increase the awareness of the community
about the significance of proper diet in the prevention of vitamin A deficiency. Although,
education is a component of all health and nutrition programmes, this has been one of
the weakest links. The health functionaries are either not properly oriented or do not
have the necessary audio-visual tools to impart nutrition education. Multi-media approach
involving communication experts will have to be adopted for success of nutrition
education efforts. Food and Nutrition Board, through its network of 67 centres has
been imparting education and training in nutrition, as well as, on home-scale preservation
of fruits and vegetables. However, efforts made, so far, have not been adequate.
Education programmes adopting social marketing (by applying marketing principles to
education campaigns) approach have been shown to be effective in changing the
behaviour of community. Box 8 highlights in brief different strategies to prevent
vitamin A deficiency.
63
Public Nutrition
Box 8 Prevention of Vitamin A Deficiency
 Supplementation with large doses of vitamin A

 Treatment of infections and infestations
 Home gardening
 Behavioural change communication
In the above section, we learnt about signs, prevalence, causes, consequences,

treatment and prevention of vitamin A deficiency. We will now move on to iron
deficiency anaemia. But first let us review what we have learnt so far.
1. Which are the three major micronutrient deficiencies affecting large segments
of population.
......................................................................................................................
......................................................................................................................
2. List the importance of Vitamin A in our body.
......................................................................................................................
......................................................................................................................
3. List the manifestations of mild and severe forms of vitamin A deficiency.
......................................................................................................................
......................................................................................................................
4. List 3 causes of Vitamin A deficiency.
......................................................................................................................
......................................................................................................................
5. List four different strategies to prevent Vitamin A deficiency.
......................................................................................................................
......................................................................................................................
We will now learn about signs, prevalence, causes, consequences, treatment and
prevention of iron deficiency anaemia.
3.3.2 Iron Deficiency Anaemia (IDA)

Iron deficiency anaemia (IDA) is the most common micronutrient deficiency in the
world, particularly in the developing countries like India. WHO, 2011 estimates suggest
that roughly 43% of children, 38% of pregnant women, 29% of non-pregnant women
and 29% of all women of reproductive age have aneamia globally.
Anaemia occurs when haemoglobin (a pigment that gives red colour to the red blood
cells) production is considerably reduced, leading to a fall in its level in the blood.
Mostly anaemia is due to iron deficiency. The other causes of anaemia may include
folate and vitamin B12 deficiency or anaemia of chronic diseases. Iron deficiency and
anaemia reduce the work capacity of individuals and entire populations, bringing serious
economic consequences and obstacles to national development. For children, health
64 consequences include premature birth, low birth weight, infections and elevated risk of
death. Later physical and cognitive development is impaired, resulting in lowered school Nutritional
performance. For pregnant women, anaemia contributes to 20% of all maternal deaths. Problems-I
Iron deficiency affects more people than any other condition, constituting a public
health condition of epidemic proportions. So, let us get to know about iron deficiency
anaemia. We begin with the signs and symptoms of IDA.
Signs and symptoms of iron deficiency anaemia
Since the level of haemoglobin is reduced in the blood, it causes paleness (pallor) on
certain parts of the body. Initially, such paleness can be seen in conjunctiva and in the
roof of the mouth. Since haemoglobin is important for carrying oxygen in the body,
anaemic individuals develop breathlessness even on milder exertion. These
manifestations exist among adults, especially in pregnant and lactating women. The
nails of finger and toes become papery thin and bend upwards to assume shape of
spoon. This condition is known as “koilonychia”. In severe cases of anaemia particularly
among pregnant women, oedema (swelling of feet) is also present. Blood examination
for haemoglobin estimation is the best way for the diagnosis of anaemia. Box 9 gives
the manifestations of iron deficiency anaemia.
Box 9 Manifestations of Iron Deficiency Anaemia
 Paleness of conjunctiva
 Paleness of tongue
 Paleness of mucosa of soft palate
 Low haemoglobin
 Swelling of feet in severe anaemia
 Koilonychia
We have reviewed the signs and symptoms of iron deficiency anaemia. Let us now
learn how common the problem of iron deficiency anaemia i.e. the prevalence is?
Prevalence of iron deficiency anaemia
We can find out about the prevalence of anaemia if we know what percentage of
population is suffering from anaemia. The WHO has recommended different cut-off
levels of haemoglobin below which an individual is considered as anaemic. These are
indicated in Table 3.9. These values are dependent on age, sex and physiological
status.
Table 3.9: WHO haemoglobin cut-off criteria
Group Cut-off for Haemoglobin

(g/100 ml)
Children < 6 years 11
Children > 6 years Adolescents
Non-pregnant and Non-lactating adult women 12
Pregnant women 11
Lactating women 12
Adult males 13
Assessment of anaemia is based on estimation of these criteria for cut-off values for
haemoglobin. You probably know that women of child bearing age, including adolescent
girls, are at the highest risk of developing anaemia followed by preschool children,
school children and adult men. NFHS-4 (2015-16) date showed that 50.3% of pregnant 65
Public Nutrition women had haemoglobin levels below 11 g/dl and the high prevelance of anaemia
among women’s are in the states like Jharkhand, Haryana, West Bengal, Bihar and
Andhra Pradesh. Also, people residing in rural areas (54%) are more anaemic than
those living in the urban areas (51%).
So far we have looked at the signs and symptoms and prevalence of iron deficiency
anaemia. Let us elaborate on what causes iron deficiency anaemia.
Causes of iron deficiency anaemia
Anaemia is a condition in which the blood cannot carry enough oxygen. This may be
because there are fewer red blood cells than normal, or because, as mentioned above,
there is not enough haemoglobin in each cell. Iron is the main component of haemoglobin.
Lack of dietary iron is the world’s leading nutritional deficiency and the most common
cause of anaemia. Let us get to know about the causes in greater details.
l Inadequate dietary intake
The commonest cause of anaemia is dietary inadequacy of iron. The dietary intakes
are usually half of the recommended dietary allowances in every age and physiological
group. In Indian communities, since cereals form the major source of iron, poor
bioavailability of iron from the habitual diets is an important cause of iron deficiency.
Isotope studies have shown that iron absorption ranges between 2-6 percent, depending
upon the type of cereal in the diet. Phytates and tannins present in Indian diet interfere
with iron absorption to a significant extent. The chemically determined iron content of
the Indian diets is apparently high (15 mg/1000 calories), but 30% of it is unabsorbable
contaminant iron. The true dietary iron content is, therefore, only 10 mg/1000 calories,
which can meet the iron requirement of adult men and children less than 6 years,
provided their dietary intake meets the energy requirements. However, in order to meet
the iron requirements of women in the reproductive age group, either the bioavailability
of dietary iron should be improved or additional iron must be supplemented.
l Poverty and ignorance
Low purchasing power of the communities and their consequent inability to meet the
nutrient requirements, even after spending 80-90% of their income on foods is an
important factor contributing to prevalence of nutritional deficiencies. Animal foods
help in increasing the bioavailability of iron, but their consumption is low due to the high
cost. In addition, due to traditional beliefs and ignorance, locally available inexpensive
sources like green leafy vegetables are not fully utilized. Similarly, the utilization of
medical and health services is also poor. Box 10 lists different causes of iron deficiency
anaemia.
Box 10 Causes of Iron Deficiency Anaemia

l Dietary Inadequacy
l Poor bioavailability of iron
l Presence of absorption interfering substances in diet
l Poverty and ignorance
Having studied about the causes, let us now learn what happens if iron deficiency
anaemia is not prevented or controlled, that is, what its consequences are.
Consequences of iron deficiency anaemia
The consequences of anaemia, particularly in women and children, are quite serious
and have far reaching implications as already discussed above. Some of these are
66 listed as follows:
l Maternal and perinatal mortality Nutritional
Problems-I
Severe anaemia in pregnancy is associated with increased risk of maternal and perinatal
mortality and foetal wastage. It is estimated that at least 80,000 women die due to
anaemia every year.
l Low birth weight
In addition, maternal anaemia contributes to high incidence of premature delivery and
low birth weight and mortality.
l Physical work and mental performance
Generally, quite often, women neglect milder forms of anaemia, but there is now
evidence showing that even a moderate reduction in haemoglobin can lower resistance
to infection and reduce work capacity.
l Poor cognitive performance in children
Anaemia in infancy and childhood is associated with poor cognitive abilities and
behavioural changes. Box 11 highlights various consequences of IDA.
Box 11 Consequences of Iron Deficiency Anaemia
l Maternal and perinatal mortality
l Low birth weight and prematurity
l Reduced physical work capacity
l Poor cognitive performance in children
We have learnt about consequences of iron deficiency anaemia. Next, how do we treat
this problem. Read the next section and find out.
Treatment of iron deficiency anaemia
Oral iron therapy is the preferred method of treatment of IDA. The dosage is decided
depending on the severity of the condition. Generally, in moderate to severe anaemia,
2 tablets of ferous sulphate (each equivalent to 100 mg of elemental iron and 500 mcg
of folic acid) are given. In view of side effects like gastric irritation, constipation, black
stools and at times joint pains, many patients discontinue treatment. They should,
therefore, be advised to consume the tablets after food. In very severe anaemia with
very low levels of haemoglobin (< 5-7 g/100 ml), packed cell transfusion is recommended.
This mode of treatment should be considered only after proper evaluation of the
subject. Sometimes, parenteral iron therapy is advised when oral iron is not tolerated
or in late pregnancies. In view of the risk of some systemic and allergic reactions, this
should be given preferably in hospitals.
We have now seen that iron deficiency anaemia is a very common problem in women
and children. It thus becomes very important that we learn about different measures
to prevent it. The next section focuses on this aspect.
Prevention of iron deficiency anaemia
As in the case of vitamin A deficiency, correction and prevention of dietary inadequacy
of iron are important sustainable methods of prevention of iron deficiency anaemia.
However, this is a long-term strategy requiring not only improvement in increasing
availability of iron in the diets but also changing behaviours of community. In view of
the widespread extent of iron deficiency anaemia, alternate methods are required to
control anaemia. A mix of approaches is necessary. The available methods of prevention
and control of anaemia are:
 Supplementation
 Food fortification
 Dietary diversification
 Education (behaviour changes)
 Health care 67
Public Nutrition Let us review each of these in detail.
 Supplementation
Supplementation with low doses of iron is necessary to prevent anaemia in particular
groups of people. Fortified foods and a good diet are not enough if a person is iron
deficient and anaemic. Consumption of supplement in the form of pills and syrup will
raise iron levels and normalize a person’s iron stores. Thereafter, dietary improvement
and consumption of fortified foods will prevent iron deficiency. Taking cognizance of
the wide spread prevalence of nutritional anaemia, the Government of India launched
the ‘National Nutritional Anaemia Control Programme’ in 1970 to prevent and control
nutritional anaemia. A detailed discussion on this programme is presented later in
Unit 10. You will learn that the beneficiaries are pregnant women, lactating women,
preschool children and family planning acceptors. Under the programme, all the
beneficiaries receive one tablet, containing iron and folic acid commonly referred to as
folifer tablets, daily for 100 days. While the adult beneficiaries get tablets containing
100 mg of elemental iron and 0.5 mg (500 mcg) of folic acid, the children (6-60
months) receive 20 mg of elemental iron and 0.1 mg (100 mcg) of folic acid. Each
beneficiary should receive a total of 100 tablets. In the case of children, each year, 100
tablets are given.
Although, the national programme has been in operation for over 30 years, the prevalence
of anaemia continues to be very high due to poor implementation of the programme
due to the following reasons:
 inadequate and irregular supplies,
 poor coverage due to lack of supervision,
 orientation of health functionaries, and
 absence of nutrition education to the illiterate community.
l Dietary diversification
It aims to ensure that deficient populations have access to foods rich in iron and also
foods rich in vitamin C (since vitamin C helps the body absorb iron). Since the
deficiencies of micronurients are common, what is needed is a strategy, which is self-
sustaining, and provides multiple nutrients at a cheaper cost to the needy population.
Home gardening and horticulture is an important strategy, which could be easily adopted
by the population to whom raising gardening is a daily practice. It does not require
large area and, in fact, an area, which can accommodate two cots, is more than
adequate to produce nutritious foods for an average family. The advantages of horticulture
approach are that it does not require external help and improves the household nutrition
security.
l Fortification
In 2016, multiple stakeholders led by the Food Safety Standards Authority of India
(FSSAI) issued a joint declaration noting that ‘‘food fortification is a realistic and
sustainable complementary strategy to food supplementation and dietary diversification
to eliminate micronutrient deficiencies.’’ Foods to consider for fortification, according
to the declaration, include milk, edible oil, rice, salt and wheat flour. Fortifying food
items with iron therefore can be an effective strategy to combat iron deficiency
anaemia.
At present, of all the food items, salt satisfies these criteria and, hence, could be a
suitable vehicle for fortification with iron. Studies conducted at the National Institute
of Nutrition clearly indicate the feasibility of fortification of salt as a simple method to
prevent and control iron deficiency anaemia. Other food items that are being fortified
68 are wheat flour and breakfast cereals. Infant weaning foods are also fortified with iron,
as milk is a poor source of iron. In India, the national nutrition policy recommends Nutritional
implementation of food fortification as a method of control of anaemia. Since iodized Problems-I
salt is already being distributed in different parts of the country, the technology of
fortification of salt with both iodine and iron has been successfully developed at the
National Institute of Nutrition, Hyderabad.
l Behaviour change communication
In communities that are illiterate and consequently ignorant of the consequences of
nutrition disorders and the relationship between diet and disease, increasing awareness
of the community about the nutrition needs and various methods of prevention is an
important method of control of anaemia. This calls for a change in the behaviour of
the community particularly the women. Unfortunately, in all the health and nutrition
programmes, education and communication are the weakest components. Use of multi
media particularly the mass media such as television and radio could contribute
significantly to the control of anaemias. The health and ICDS functionaries now
commonly adopt interpersonal communication. The education efforts should be
persuasive, repetitive and supported by adequate audio-visual aids. Street plays and
folk arts are also increasingly being used now a days.
l Strengthening the public health measures
Parasitic infestations and protozoal infections cause iron deficiency through loss of
blood or destruction of red blood cells. Deworming and prevention and treatment of
malaria and diarrhoea could help in controlling anaemia significantly. Simultaneous
education of the community about methods of protection against these would help in
the control of anaemia. Box 12 lists various methods of prevention of iron deficiency
anaemia.
Box 12 Methods of Prevention of Iron Deficiency Anaemia

l Supplementation with iron and folic acid tablets
l Food fortification
l Increased access to iron rich foods
l Education on dietary practices
l Disease prevention
In the above section, we learnt about signs, prevalence, causes, consequences, treatment
and prevention of iron deficiency anaemia. We will now move on to iodine deficiency
disorders after rewaring the questions given in the check your progress exercise 3.

1. What is anaemia? List four signs and symptoms of iron deficiency anaemia.
..........................................................................................................................
..........................................................................................................................
2. Fill in the blanks:
a. Women of child bearing age, including adolescent girls, are at the ...........
................. risk of developing anaemia.
b. A number of sample surveys carried out recently showed that ............of
pregnant women had haemoglobin levels below 11 g/dl.
c. The most common cause of iron deficiency anaemia is .........................
inadequacy of iron.
d. Absorption of iron in the usual Indian vegetarian diet is around ................
........ percent.
e. ............ foods help in increasing the bioavailability of iron; but their
consumption is low due to the high cost.
69
Public Nutrition
3. Answer the following briefly:
a. List four main consequences of iron deficiency anaemia.
..................................................................................................................
..................................................................................................................
b. Why does prevalence of iron deficiency anaemia continue to remain high
in India?
..................................................................................................................
..................................................................................................................
Let us now learn about Iodine Deficiency Disorders.
3.3.3 Iodine Deficiency Disorders

Iodine is an essential micronutrient required for the normal mental and physical growth
and development of man. Iodine deficiency is a naturally occurring ecological phenomenon
that is present in many parts of the world. About 1.88 billion people are at risk of iodine
deficiency and 241 million children have an inadequate iodine intake. In our country
200 million people ar at risk of IDD’s and another 71 million are suffering from goitre
and other IDDs. Traditionally the endemic goitre belt in our country stretches across
the entire sub-Himalayan belt extending from Jammu and Kashmir to Arunachal Pradesh.
In addition, a number of new regions have been identified in Andhra Pradesh, Karnataka,
Kerala, Maharashtra, Punjab, Tripura, Nagaland and Meghalaya.
The term iodine deficiency disorders (IDD) includes a spectrum of disabling conditions
affecting the health of human beings starting from foetal life through adulthood
resulting from inadequate dietary intake of iodine. We will explain this term in
more detail in the next few paragraphs. Let us begin our study on IDD by getting to
know about the signs and symptoms of this disabling condition.
Signs and symptoms of iodine deficiency disorders
Before we discuss the signs and symptoms of iodine deficiency disorders, let us first
understand why we need iodine in our body. Iodine is required in our body for the
synthesis of thyroxine, which you may already know is the hormone produced by the
thyroid gland. When iodine intake falls below the recommended levels, the thyroid
gland is no longer able to synthesize sufficient amounts of thyroxine hormone. One of
the well-recognized features of iodine deficiency disorders is goitre. Thyroid gland in
its efforts to produce the required thyroxine, in the presence of iodine deficiency, swells
up leading to enlargement of the thyroid gland as illustrated in Figure 3.4. This condition
is known as goitre, which is more a cosmetic problem. The real health problems are
because of functional failure of thyroid gland in different stages of individual development.
Let us get to know about these problems.
70 Figure 3.4: Goitre

Iodine deficiency in the mother interferes with the development of the unborn child. Nutritional
Problems-I
In many cases, iodine deficiency can cause abortions, congenital abnormalities and
increased perinatal mortality. The major effect of foetal iodine deficiency is endemic
cretinism. It is characterized by growth failure, mental deficiency, deaf mutism and
spastic paralysis of legs. Inadequate production of thyroid hormone leads to
hypothyroidism. Hypothyroidism is the principal factor responsible for the damage
done to the developing brain and the other harmful effects known collectively as
iodine deficiency disorders (IDD). Populations residing in iodine deficient areas
exhibit low intelligence, lack of initiative and poor decision making capacity. Box 13
highlights various signs and symptoms/manifestations of IDD.
Box 13 Manifestations of IDD
l Goitre
l Abortions, Congenital abnormalities
l Increased perinatal mortality
l Cretinism
You have learnt about signs and symptoms of IDD. We hope having gone through the
discussion above the whole spectrum of disabling conditions caused due to IDD must
be clear. Let us now look at the prevalence of IDD.
Prevalence of IDD
We can determine the prevalence of IDD by conducting population surveys. Most
of the population surveys are based on clinical assessment of goitre and cretinism,
which are the two classical features of iodine deficiency. Before we discuss the
prevalence of IDD, let us find out the WHO criteria for classification of goitre size.
For clinical assessment of goitre, a standard technique based on palpation of thyroid
is used through which goitre size can be assessed. Table 3.10 gives the WHO criteria
for classification of goitre size. The sum of grades 1 and 2 provides Total Goitre Rate
(TGR). IDD is considered to be a public health problem, if the TGR is more than in
10% of the children aged 6-12 years in an area.
Table 3.10: Classification of goitre
Grade ‘0’ No goitre (Neither palpable nor visible, palpable but the size is less
than the distal phalange)
Grade ‘I’ Not visible when neck is in normal position, but palpable (The size of
the enlargement of the gland should be more than the size of the distal
phalange of the thumb of the subject.
Grade ‘II’ Visible from the minimum distance.
As per NFHS-4 overall 1245 women and 287 men per one lakh population have been
suffering from goitre or any other thyroid disorder in the state which has iodine
coverage of about 93 percent. High prevalence of IDD is found in the states like
Himachal Pradesh, Tripura, West Bengal and Andhra Pradesh.
Epidemiological assessment of IDD also requires a measure of dietary iodine, which

is provided by urinary iodine excretion. Determination of iodine in random urine
71
Public Nutrition samples, which is more convenient, provides a good indication of the level of iodine
nutrition. Urinary iodine content of > 10 mg/dl is normal. In some of the areas, despite
prevalence, which is indicative of endemicity, urinary iodine levels are in the normal
range.
It must be evident to you that IDD is widely prevalent in our country. Let us now
review the causes of IDD.
Causes of iodine deficiency disorders

We have studied above that iodine deficiency is a naturally occurring ecological
phenomenon that is present in many parts of the world. The main cause of iodine
deficiency in soils is leaching by floods or high rainfall. Mountainous regions including
the Himalayas therefore have some of the highest prevalence of iodine deficiency.
Iodine deficiency also occurs due to flooding; for example, in India around the Ganges.
In areas of endemic iodine deficiency, the water and foods (plants and animals grown
there) have low iodine content. Let us get to know about the causes next.
l Environmental deficiency of iodine: The ultimate causative factor is low intake

of iodine. Iodine occurs in soil and sea as iodide, the ions of which are oxidized
by sunlight to elemental iodine (which is volatile). Iodine in the atmosphere returns
to soil by rain. The return of iodine, however, is slow and small in amount
compared with original loss. In hilly slopes, repeated flooding leaches out the
iodine from soil or erodes topsoil causing iodine deficiency in the soil. All crops
grown in this soil will, therefore, be iodine deficient. As a result, human and
animal populations, which are totally dependent on food grown in such soil, become
iodine deficient.
l Goitrogens: Certain chemical substances like thiocyanates, phenols, disuphides,

flavanoids etc, found in the environment, can interfere with iodine metabolism.
These substances are known as goitrogens, which could cause goitre. Common
foods such as cabbage, sorghum, finger millets and mustard contain goitrogens.
Although excessive intake of such foods can cause goitre, this appears to be of
secondary importance in the etiology of endemic goitre, at least in India.
Let us now review the consequences of IDD.
What are the consequences of IDD?

As discussed earlier under signs and symptoms, the consequences of IDD include:
mental retardation, other defects in the development of the nervous system, goitre,
physical sluggishness, growth retardation, reproductive failure, increased childhood
mortality and lowered economic productivity. Cretinism is the result of iodine deficiency
during pregnancy, which adversely affects foetal thyroid function. Neurological cretinism
is characterized by poor cognitive ability, deaf mutism, speech defects, and proximal
neuromotor rigidity. It is much more prevalent than myxoedematous cretinism which
includes hypothyroidism with dwarfism. Maternal iodine deficiency during pregnancy
is associated with a higher incidence of stillbirths, abortions and congenital abnormalities.
Iodine deficiency has been called the world’s major cause of preventable mental
retardation. So, then what can be done to prevent this disabling condition? Read and
find out.
Prevention of IDD
Many approaches to reduce iodine deficiency have been formulated. Some of these
are reviewed herewith:
Iodized salt distribution: Since, IDD is due to reduced uptake of iodine by human
body from the environment, the control measures essentially aim to ensure sufficient
intake of iodine by persons living in iodine deficient environment. The oldest and the
72 commonest control measure is fortification of common salt with potassium iodate. In
India, the efficacy of iodized salt in the control of endemic goitre was first established Nutritional
in Kangra Valley of Himachal Pradesh. Subsequently, the Government of India launched Problems-I
the National Goitre Control Programme, in 1962, to supply iodized salt in endemic
areas. Although, the programme has been in operation for the last three decades, it
has gained momentum only recently. Available evidence indicates that iodized salt
consumption is quite safe even in non-endemic areas.
Communication campaign: A mass communication campaign is needed to create

awareness in the community about the consequences of IDD and the benefits of
iodized salt. The community should be made aware of the ill effects of iodine deficiency
and the advantages of iodized salt. They should be encouraged to consume iodized salt
daily.
Double fortified salt: Since, iron deficiency anaemia and iodine deficiency disorders
often co-exist, the most effective approach to control these public health problems
would be simultaneous fortification of salt with iron and iodine. The technology for
double fortification of salt has been successfully developed at NIN. Laboratory studies
have shown satisfactory results with respect to stability and bioavailability of iron and
iodine. Large-scale community trials are underway for field-testing the double fortified
salt.
Iodized Oil: The other approach employed as a specific measure for women and
children in hyper-endemic areas is injection of iodized oil. Intramuscular injection of
iodized oil has been used for tackling goitre and cretinism in hyper-endemic areas in
many countries of the world. The advantage of the injection procedure is that a single
dose of 1 ml will provide protection for 3-5 years. Though, it has been found to be
effective, the high cost and the difficulty in reaching all the victims of IDD make this
approach less practicable. The use of disposable syringes, as a result of the risk of
hepatitis-B and HIV AIDS, is now mandatory. Box 14 highlights methods of prevention
and control of IDD.
Box 14 Prevention and Control
 Iodized salt
 Iodized oil injection
 Double fortified salt
 Mass communication
We have just learnt about manifestations, prevalence, causes, prevention and

control of iodine deficiency disorders. Finally, let us now learn briefly about zinc
deficiency.
3.3.4 Zinc Deficiency

Evidence suggests that nearly one-third of preschool children in lower-income countries
have stunted growth, and that a considerable proportion of this growth failure is likely
attributable to zinc deficiency.
Zinc is a cofactor for a large number of 200 metalloenzymes, which regulate several
cellular functions of the body. Zinc is essential for cell division and growth, stabilization
of bio-membranes, protection against free radical damage, immune function and its
possible role in testosterone production. Zinc, in the recent past, has attained an
important place as an important trace element. We will briefly study here the signs,
symptoms and the consequences of zinc deficiency and the recommended daily
requirements for zinc.
73
Public Nutrition Consequences of zinc deficiency
Signs of zinc deficiency are the result of suppression of one or more of its biological
functions. The clinical features of zinc deficiency are nonspecific and the disorder is
of slow onset from the age of weaning. Poor appetite is the earliest clinical feature
of zinc deficiency leading to growth retardation. Its characteristic manifestations are
skin lesions, loss of hair, failure to thrive and diarrhoea. Zinc deficiency can occur in
several pathological conditions like chronic alcoholic liver disease, sickle cell anaemia
and chronic malabsorption like celiac disease.
The severity and manifestations of frank zinc deficiency may vary at different ages.
In infants up to 2 months of age, diarrhoea is a prominent symptom. Early zinc
deficiency leads to cognitive function impairment, behavioural problems, mood changes,
memory impairment, problems with spatial learning, and neuronal atrophy (optic and
cerebellar). Skin problems become more frequent and gastrointestinal problems, anorexia,
and mood changes less frequent as the child grows older. Alopecia (hair loss), growth
retardation, blepharoconjuctivitis (inflammation of eyelids and conjuctiva), and recurrent
infections are common findings in school-aged children. Chronic non-healing leg ulcers
and recurrent infections occur among the elderly.
Adverse consequences of maternal zinc deficiency on pregnancy outcome include
intrauterine growth retardation, low birth weight, poor foetal neurobehavioural
development and increased neonatal morbidity. Adverse maternal outcomes include
preterm delivery and pregnancy induced hypertension. Figure 3.5 summarizes the
consequences of maternal zinc deficiency. Outcomes observed in randomized, controlled
zinc supplementation trials are shaded in the Figure, indicating greater confidence in
their association with zinc deficiency. Unshaded outcomes are those derived from
observational studies of human maternal zinc status and pregnancy outcome, and their
association with zinc deficiency can be considered only tentative.
Maternal zinc deficiency



Adverse maternal Adverse foetal outcomes
outcomes
 Intrauterine growth
 Preterm labour
retardation
 Prolonged labour
Induction of labour  Conenital
 Placental abruption
 Premature rupture of
  Increased assisted or  malformations
operative deliveries  Spontaneous
membrances
 Inefficient uterine
abortions
 Foetal distress
contractions
 
Poor neonatal health
Poor maternal health
Low birth weight

 Pregnancy-induced 
hypertension  Poor neurobehavioural

development
 Preeclampsia   Increased/recurrent
 Maternal lacerations
morbidity in low-birth-
 Intra-or postpartum
weight neonates
haemorrhage
 Postpartum  Reduced maturity
malutrition and  Low Apgar score, ashyxia
infections  Neonatal sepsis
Figure 3.5: Possible consequences of maternal zinc deficiency on birth outcomes and
maternal and perinatal health
Source: International Zinc Nutrition Consultative Group (IZiNCG) Technical Document #1
Considering the likely common occurrence of zinc deficiency and the critical roles of
adequate zinc nutrition in supporting normal growth and development, preventing morbidity
74 from common infections, and possibly reducing child mortality, it is important that we
review the zinc requirements. Table 3.11 gives the estimated physiological requirements Nutritional
Problems-I
for absorbed zinc during childhood by age group and sex, and during pregnancy and
lactation, as suggested by ICMR (2010).
Table 3.11: Estimated physiological requirements for absorbed zinc during

childhood by age group and sex, and during pregnancy and lactation.
ICMR (2010)
Age Reference Physiological
Sex Weight (kg) Requirement (mg/day)
1-3 yrs 12.9 5
4-6 yrs 18 7
7-9 yrs 25.1 8
10-12 yrs, M 34.3 9
10-12 yrs, F 35 9
13-15 yrs, M 47.6 11
13-15 yrs, F 46.6 11
16-17 yrs, M 55.4 12
16-17 yrs, F 52.1 12
Pregnancy - 12
Lactation - 12
Zinc occurs in a wide variety of food sources, but is found in highest concentrations
in animal food sources, particularly in the organs and/or flesh of beef, pork, poultry,
fish and shellfish, and with lesser amounts in eggs and dairy products. Zinc content
is relatively high in nuts, seeds, legumes, and whole-grain cereals, and is lower in
tubers, refined cereals, fruits, and vegetables. Average ranges of zinc content (mg/100
g fresh weight) and zinc density (mg/100 kcal) in a variety of food sources are
summarized in Table 3.12.
Table 3.12: Zinc content, zinc density of commonly consumed foods

Zinc Content
Food Groups mg/100 g mg/100 kcal

Liver, kidney (beef, poultry) 4.2-6.1 2.7-3.8
Meat (beef, pork) 2.9-4.7 1.1-2.8
Poultry (chicken, duck, etc.) 1.8-3.0 0.6-1.4
Seafood (fish etc.) 0.5-5.2 0.3-1.7
Eggs (chicken, duck) 1.1-1.4 0.7-0.8
Dairy (milk, cheese) 0.4-3.1 0.3-1.0
Seed, nuts (sesame, pumpkin, almond, etc.) 2.9-7.8 0.5-1.4
Beans, lentils (soy, kidney bean, chickea, etc.) 1.0-2.0 0.9-1.2
Whole-grain cereal (wheat, maize, brown rice, etc.) 0.5-3.2 0.4-0.9
Refind cereal grains (white flour, white rice, etc.) 0.4-0.8 0.2-0.4
Bread (white flour, yeast) 0.9 0.3
Fermented cassava root 0.7 0.2
Tubers 0.3-0.5 0.2-0.5
Vegetables 0.1-0.8 0.3-3.5
Fruits 0-0.2 0-0.6
75
Public Nutrition Leucocyte zinc, erythrocyte zinc, hair zinc and saliva zinc are some of the indices
suggested, for assessment of Zn status, though they are not considered to be good
indices. Though zinc deficiency is not a public health problem, some protagonists
recommend zinc supplementation particularly to children. So far, there is no agreement
on this aspect. Finally, because of the likely widespread occurrence of zinc deficiency,
especially in low-income groups, and the important health consequences of this condition,
efforts are needed to define more precisely the risk of zinc deficiency in vulnerable
populations and to develop programmes to control this condition where necessary.
a. What is the importance of iodine in our diet?
..................................................................................................................
..................................................................................................................
b. List at least four manifestations of iodine deficiency disorders.
..................................................................................................................
..................................................................................................................
2. Read the following statements carefully. Indicate whether each is true or false.
Correct the false statement.
a. IDD is considered to be a public health problem, if the total goitre rate is
more than 5% of the children aged 6-12 years in an area.
b. None of the state in India has been found endemic for goitre.
c. When the human beings are totally dependent on the foods grown on iodine
deficient soil, they become iodine deficient.
d. Iodine deficiency is world’s major cause of preventable mental
retardation.
e. Consumption of iodized salt is one of the most cost effective and feasible
strategy to prevent iodine deficiency disorders.
3. List four signs and symptoms of zinc deficiency.
..........................................................................................................................
..........................................................................................................................
3.4 LET US SUM UP

In this unit you learnt about the macronutrient and micronutrient deficiencies in our
body. Protein Energy Malnutrition (PEM) is a macronutrient deficiency or a deficiency
of calorie and protein. Of all the micronutrient deficiencies, those of vitamin A, iron and
iodine affect millions of populations and contribute to high morbidity and mortality. Let
us summarize each of this deficiency as follows:
l PEM forms the most important nutritional deficiencies of public health significance.
The term PEM is used to describe a wide range of clinical and subclinical
conditions in the child. Although the prevalence of severe forms of clinical conditions
i.e, kwashiorkor and marasmus has declined substantially over a period of time,
the prevalence of subclinical forms of PEM remains very high. About 35.7% of
children <5 years of age remain underweight.
76
l Vitamin A deficiency manifests in the form of eye lesions, which are grouped Nutritional
under Xerophthalmia. Causes of Vitamin A deficiency are poor diet, poverty, Problems-I
ignorance and infections. Vitamin A deficiency can be prevented through food
based approach ( which includes improving diet through food fortification and
home gardening), supplementation, treatment of infections and behaviour change
communication.
l Iron deficiency anaemia is the commonest micronutrient deficiency in the world.
Women of child bearing age, including adolescent girls, are at the highest risk of
developing anaemia followed by preschool children, school children and adult
men. Consequences of iron deficiency anaemia include maternal and perinatal
mortality, low birth weight and prematurity, reduced physical work capacity and
poor cognitive performance in children. Iron deficiency anaemia can be prevented
by supplementation, food fortification, dietary diversification, behaviour change
communication and appropriate health care.
l Iodine is required for the synthesis of thyroid hormone. Iodine deficiency leads to
range of disorders affecting fetus, newborn, school children and adults. The
manifestations of iodine deficiency disorders include goitre, abortions, congenital
abnormalities, cretinism, deaf mutism and low intelligence. Consumption of iodized
salt is one of the most cost effective and feasible strategy to prevent iodine
deficiency disorders.
3.5 GLOSSARY
Bronchopneumonia : inflammation of lungs
Congenital : by birth
Deaf mutism : a person who is deaf and dumb
Endemic : localized to certain region
Septicemia : blood poisoning

EXERCISES
1. The different clinical forms of PEM are: Kwashiorkor, Marasmus, and
Marasmic kwashiorkor.
2. Table showing differences between kwashiorkor and marasmus.
Manifestation Kwashiorkor Marasmus
Oedema Present Absent
Weight-for-age <80% of Standard <60% of Standard
Hair Changes Present Absent
Skin Changes Present Absent
Moon face Present Absent
Hanging Skin folds Absent Present
3. The different classifications used for detection of sub clinical PEM is body weight
for age are: Indian Academy of Paediatrics Classification, and Standard Deviation
Classification. 77
Public Nutrition 4. The criteria used for the classifications based on % NCHS standards weight
for age
Grade of PEM Indian Academy of Paediatrics
Normal >80%
I 70-80%
II 60-70%
III 50-60%
IV <50%
5. The main principles in the treatment of severe PEM are:

 Dietary treatment: Energy: 170-200 kcal per kg of body weight, Protein:
3-4-g/kg of body weight
 Provision of vitamin and mineral supplements
 Oral Rehydration
 Control of infections
 Control of infestations
6. The most important component to prevent and control PEM is to ensure that the
children consume balanced meal daily. The life cycle approach at the family level
is the most appropriate. The interventions of the Government in general emphasize
on the following:
Supplementary Feeding; Control of common child hood infections, Ensuring nutrition
security through public distribution of food grains, Immunization against common
childhood diseases, Behaviour change communication, and Increasing purchasing
power through programmes of poverty alleviation.
1. The three major micronutrient deficiencies affecting millions of populations, are
Vitamin A iron and iodine.
2. Vitamin A is essential for maintenance of healthy epithelium and normal vision.
3. Manifestations of vitamin A deficiency are: night blindness, conjunctival xerosis,
bitot spots, corneal xerosis, corneal ulcer and keratomalacia.
4. Three causes of Vitamin A deficiency are inadequate diet, poverty and ignorance,
and infections.
5. Four different strategies for prevention of Vitamin A deficiency are supplementation
with large doses of vitamin A, treatment of infections and infestations, home
gardening, and behavioural change communication.
1. Anaemia is defined as a reduction in haemoglobin levels in the blood. Four signs
and symptoms of iron deficiency anaemia are paleness of conjunctiva, paleness
of tongue, breathlessness, and swelling of feet in severe anaemia.
2. a. highest
b. 60-80
c. dietary
d. 2-6
78 e. Animal
3. a. Main consequences of iron deficiency anaemia are maternal and perinatal Nutritional
mortality, low birth weight and prematurity, reduced physical work capacity, Problems-I
and poor cognitive performance in children.
b. The prevalence of anaemia continues to remain very high in India due to
poor implementation of the National Nutrition Anaemia Control Programme.
The reasons are inadequate and irregular supplies of iron and folic acid
tablets, poor coverage due to lack of supervision, orientation of health
functionaries, and absence of nutrition education to the illiterate community.
1. a. Iodine is an essential micronutrient required for the normal mental and physical
growth and development of man. Iodine is required for synthesis of thyroid
hormone called thyroxine.
b. Manifestations of iodine deficiency disorders are: goitre, abortions, Congenital
abnormalities, increased perinatal mortality, cretinism, deaf mutism, and low
intelligence.;
2. a. False, TGR in more than 10% children
b. False.
c. True
d. True
e. True
3. Signs and symptoms of zinc deficiency are skin lesions, loss of hair, growth
retardation, and diarrhoea.
79
Public Nutrition
UNIT 4 NUTRITIONAL PROBLEMS-II
Structure
4.1 Introduction
4.2 Vitamin Deficiencies
4.2.1 Beriberi
4.2.2 Ariboflavinosis (Riboflavin Deficiency)
4.2.3 Pellagra
4.2.4 Folic Acid and B12 Deficiency
4.2.5 Scurvy
4.2.6 Rickets and Osteomalacia
4.3 Fluorosis
4.4 Lathyrism
4.5 Let Us Sum Up
4.6 Glossary
4.1 INTRODUCTION
In the previous unit, we learnt about protein energy malnutrition and the commonly
occurring micronutrient deficiencies of vitamin A, iron and iodine. These nutritional
deficiencies are widely prevalent in India and other developing countries. They cause
illness and death in a large number of people, especially in women and children.
Other micronutrients found in food, including vitamins such as thiamine, niacin, riboflavin,
folate, vitamin C and D can also significantly affect health when dietary deficiencies
exist. As a public nutrition professional, it is very important for us to know about these
problems. In this unit, we will learn about the deficiency diseases caused when there
is a lack of these vitamins in the diet. We will also learn about fluorosis and
lathyrism. However, these are not vitamin deficiency diseases. Fluorosis is caused
by excess of fluoride in water. Lathyrism is caused by neurotoxin present in
kesari dal. These diseases cause many complications in our body. So it is important
for us to learn about them.
Objectives
After studying this unit, you should be able to:
l describe the significance of common deficiencies of vitamin B-complex,
C and D;
l understand the problem of fluorosis and lathyrism in Indian population;
l identify cases of these nutritional problems;
l enumerate their causes and consequences; and
l educate the families and communities about the methods of their prevention.
4.2 VITAMIN DEFICIENCIES

We already know that vitamins are very essential to support growth and
development in our body. They are not synthesized by our body and so need to be
80 supplied in the daily diets in small quantities to satisfy the requirements and maintain
good health. B-complex vitamins and Vitamin C being water-soluble are not stored Nutritional Problems--II
in the body, are easily excreted and hence, their deficiencies are generally encountered.
In addition, deficiency of a fat soluble vitamin  vitamin D is also encountered in
some areas. Box 1 lists clinical deficiency related to each vitamin.
Box 1 Clinical Deficiency Related to the Vitamins
Vitamins Clinical Deficiency
Thiamine (B1) Beriberi
Riboflavin (B2) Ariboflavinosis
Niacin Pellagra
Folic Acid and B12 Megaloblastic and Pernicious anaemia
Ascorbic acid (vitamin C) Scurvy
Vitamin D Rickets and Osteomalacia
Let us elaborate upon each of the vitamin deficiency in detail. We shall begin with
deficiency of thiamine i.e. beriberi. We will study about the manifestations, cause,
prevention and treatment of thiamine deficiency.
4.2.1 Beriberi
Beriberi, which is caused by the deficiency of vitamin B1 (i.e. thiamine), was once
a major disease problem in many parts of the developing world, including India.
Today, the prevalence of beriberi has been greatly reduced. Beriberi occurs in
people whose staple diet consists mainly of polished white rice, which contains little
or no thiamine. Therefore the disease has been seen traditionally in people in Asian
countries (especially in the nineteenth century and before) and in chronic alcoholics
with impaired liver function.
Bontius (1642) and Nicolaas Tulp (1652) were the Dutch physicians, who gave
the first clinical descriptions of beriberi. Tulp’s description of beriberi was a
detailed one, but interestingly he had no clues that it was a dietary deficiency
disease. This discovery came more than two hundred years later. In fact, thiamine
deficiency, which causes damage to central and peripheral nervous system and the
heart, has been known well before even the vitamine (vitamin B1) was discovered
in the year 1926. The disease is now rather rare. Let us learn about the manifestations
of this disorder.
Manifestations
A brief review of the manifestations of thiamine deficiency is also presented in the
Advance Nutrition Course (MFN-004) in Unit 8. We suggest you look up the unit
now. You would realize that beriberi is of different types described as cardiac
beriberi (wet beriberi), dry beriberi and infantile beriberi. The severity of
deficiency depends upon the degree and duration of deficiency. The early clinical
features are anorexia and dyspepsia, associated with heaviness and weakness of the
legs. There is tenderness of the calf muscles on pressure with complaints of ‘pins
and needles’ pain and numbness in the legs. The knee jerks are usually sluggish but
occasionally slightly exaggerated. The subjects feel weak and get easily exhausted
while working. A brief description of the different types of beriberi mentioned
above follows.
Cardiac beriberi is the wet type and the signs and symptoms are of ventricular
failure characterized by difficulty in breathing, particularly on physical exertion, 81
Public Nutrition palpitation, cyanosis and oedema. Remember, oedema is the important feature of
wet beriberi. It may develop rapidly and involve not only the legs but also the face,
trunk and serous cavities.
Dry beriberi is milder form of the disease with polyneuropathy with clinical signs
characterized by numbness, burning sensation  commonly referred to as ‘pins and
needles’ in the limbs, tenderness of muscles, muscle cramps and weakness in limbs.
The muscles become progressively wasted and weak and walking becomes difficult.
The emaciated subject needs the help of sticks to stand and walk and finally becomes
bed-ridden. If not treated, the patients will die.
Infantile beriberi, seen among breast-fed infants, perhaps, is due to low thiamine
in mother ’s milk. Two types of infantile beriberi are known. These are: (i)
cardiovascular type, and (ii) neuritic type. Let us get to know about them.
i) The cardiovascular type (wet): It manifests itself in babies between the ages
of 2 and 4 months. The onset is acute with classical signs and symptoms of
congestive cardiac failure, tachycardia (rapid heart beat), dyspnoea (difficulty in
breathing), enlargement of the heart, elevated venous pressure, enlarged tender
liver, dependent oedema and oliguria (infrequent urination). In some infants,
cyanosis and pulmonary oedema may develop rapidly and death may ensure in
a matter of few hours.
ii) The neuritic type (dry): It shows typical manifestations of peripheral neuropathy,
tenderness of calf muscles, diminished tendon jerks, hyperaesthesia, is rare in
children, but a pseudo-meningeal form, (cerebral or Wernicke’s syndrome) tends
to occur in older infants between 8 and 10 months of age. The accent is
predominantly on the C.N.S. with sensorial alteration (irritability, apathy,
drowsiness and coma) signs of raised intracranial tension, staring expression
and varying degrees of neurologic deficit.
Having studied about the manifestations, it is important to understand that if not
attended to immediately, beriberi can lead to loss of speech, convulsions, coma and
ultimately death. In chronic alcoholics, thiamine deficiency is characterized by
encephalopathy (disease of the brain), which manifests as confusion, polyneuropathy,
and certain changes in eyes. It may cause forgetfulness, depression and delirium. For
your recapitulation Box 2 lists types of beriberi.
Box 2 Types of Beriberi

l Cardiac Beriberi
l Dry Beriberi
l Infantile Beriberi
l Poly neuropathies
Next, let us learn about the causes of beriberi.

Causes
Some of the important causes of beriberi are consumption of highly polished rice and
improper cooking practices such as throwing away the excess water after cooking
the rice. You must have read in the Advanced Nutrition Course (MFN-004) that the
thiamine requirements are related to the quantity of calories consumed by an individual
viz 0.5 mg per 1000 calories/day. Consumption of foods of higher energy with lower
thiamine content leads to lower vitamin energy ratio. The at-risk groups include
children, adolescents, athletes and elderly. Deficiency of thiamine is also very common
among chronic alcoholics. So then what measures can we adopted to treat and
82 prevent this disorder? Read the next section and find out.
Treatment Nutritional Problems--II
The specific treatment of beriberi is the administration of thiamine. Parenteral

administration of thiamine in doses of 10-20 mg twice or thrice a day gives dramatic
results. Care is required as it can lead to anaphylactic (hypersensitivity) reactions.
Oral administration of 5-10 mg of thiamine for longer durations is preferred. Larger
doses are wasteful.
Let us next review how beriberi can be prevented.
Prevention
In the community, there are several possible approaches to the prevention of beriberi.
Diversification of the diet or the encouragement of the use of parboiled or undermilled
rice i.e. avoiding excess milling and the consequent high polishing of rice are logical
approaches. Similarly, adopting proper cooking practices such as not using and throwing
excess water for cooking of rice would help in the retention of thiamine. Parboiling
and hand-pounded rice are good sources of vitamin B1.. The communities should be
educated to consume foods regularly, which are rich in thiamine (such as whole grain
cereals, raw and hand-pounded or parboiled rice, pulses, wheat germ etc.) and
should be encouraged to avoid excessive consumption of alcohol.
After thiamine, next let us learn about them manifestation, cause, prevention and
treatment of riboflavin deficiency i.e. ariboflavinosis.
4.2.2 Ariboflavinosis (Riboflavin Deficiency)

Riboflavin is one of the important B-complex vitamin, the deficiency of which is
encountered in our communities frequently. Surveys carried out in different areas of
the country indicated that it is prevalent among the poorer groups of population of
all ages, particularly among children and pregnant and nursing women. It is also
common in elderly population.
Riboflavin, we know, is involved as a cofactor in a number of the respiratory

enzymes (flavin adenene dinucleotide (FAD), and flavin mononucleotide (FMN)),
which are involved in energy metabolism. Thus it plays a major role in intermediary
metabolism. The dietary deficiency of this vitamin, therefore, leads to a condition
called ariboflavinosis, characterized by mouth lesions. Let us learn about its
manifestations in greater details.
Manifestations
Lesions in mouth and tongue, skin, corneal and haematological changes, characterize
the deficiency of riboflavin. The commonest signs are angular stomatitis (cracks
at the angles of the mouth), glossitis (sore tongue) and cheilosis (ulcers on lips)
as illustrated in Figure 4.1. Angular stomatitis may progress to fissures at the
angles of the mouth. Sometimes, fungal infection may supervene. In glossitis, the
tongue is acutely inflamed and papillae (projections) on the tongue become
hypertrophic (prominent), sometimes, the papillae also get atrophic (decreare in size),
producing bald tongue. The hypertrophic papillae produce the classical magenta red
tongue and as the disorder advances, the papillae get atrophic. In cheilosis, one
of the features of chronic eficiency, mucous membrane of the lips denudes and ulcers
are formed. Nasolabial dyssebaceae, a seborrhic type of dermatitis involving facial
skin is also often seen in ariboflavinosis. Rarely, eye symptoms like
photophobia (inability to see brightness) are also reported. Corneal vascularization
may also occur in riboflavin deficient. Box 3 summarizes the manifestations of
riboflavin deficiency.
83
Public Nutrition
a) Angular stomatitis b) Glossitis c) Cheilosis
Figure 4.1: Manifestations of riboflavin deficiency
Box 3 Manifestations of Riboflavin Deficiency
l Angular stomatitis
l Glossitis
l Cheilosis
l Nasolabial Dyssebaceae
Let us learn about the causes of riboflavin deficiency, next.
Causes
Dietary inadequacy is usually the cause of riboflavin deficiency. Inadequate

consumption of pulses, nuts and milk products, which the households belonging to
the low socioeconomic groups cannot afford, is the main reason for the wide spread
riboflavin deficiency in the country. Alcoholism, malabsorption, tuberculosis,
hyperthyroidism and chronic infections are also associated with ariboflavinosis. Certain
drugs can also induce it.
So, then how can ariboflavinosis be treated? Let us find out.
Treatment
Oral administration of 5-10 mg of riboflavin daily is often satisfactory to treat

riboflavin deficiency. In subjects suffering from malabsorption, parenteral riboflavin
may be given.
Let us learn how we can prevent riboflavin deficiency.
Prevention
Improvement of diets to ensure adequate riboflavin daily is the most rational solution
to prevent riboflavin deficiency. For poorer populations, foods providing riboflavin
like pulses, nuts and milk products are expensive. Supplements of riboflavin to
vulnerable segments like pregnant women are often recommended.
Next let us move on to the deficiency of niacin i.e. pellagra. We will study about
the manifestations, cause, prevention and treatment of pellagra.
84
4.2.3 Pellagra Nutritional Problems--II
Pellagra was considered to be an infectious disease until the early 20th century. It
was only in 1917 that Joseph Goldberger succeeded in proving that the disease was
caused by nutritional deficiency.
Pellagra is a disease that occurs when a person does not get enough niacin
(one of the B complex vitamins) or tryptophan (an amino acid) in their diet. It can
also occur if the body fails to absorb these nutrients. Pellagra, due to niacin deficiency,
was very common in countries like Mexico where maize was the staple. Niacin was
demonstrated to be anti pellagra factor in 1937. What are the manifestations of
pellagra? The next section focuses on this aspect.
Manifestations
Pellagra is seen generally in individuals in the age group of 20 and 50 years, in both
the sexes. To start with, it may manifest with nonspecific symptoms like weakness,
limited capacity for work, loss of appetite, nausea, early fatigue and some
gastrointestinal disturbances, anxiety and sleeplessness. It is sometimes reported that
considerable proportion of patients attending mental hospitals may be suffering
from pellagra. The classical manifestations of niacin deficiency are dermatitis,
diarrhoea and dementia (commonly referred to as 3 Ds) and can lead to death (the
fourth D).
The dermatological changes, called “pellagra”, are usually the most prominent.
Dermatosis in pellagra is seen typically in areas exposed to sun (photosensitive). It
is seen on the exposed parts of the body like the upper and lower extremities, face
and neck as can be seen in Figure 4.2(a). It may be symmetrical and bilateral (on
both the sides). The lesions are aggravated by exposure to skin. The lesion starts
with erythema resembling sunburn, which is symmetrically distributed on the parts of
the body exposed to direct sunlight-the backs of the hands and forearms up to the
rim of the sleeves (“pellagra gloves”), the feet and legs up to the edge of the
trousers or skirt, the forehead, and on the nose and cheeks in a butterfly distribution.
The skin lesions on the neck appear in the form of necklace, generally referred to
as “Casal’s necklace” as illustrated in Figure 4.2(b).
(a) Skin lesions on the hand (b) Skin lesions on the neck
Figure 4.2: Manifestations of pellagra
Pellagra patients usually complain of nausea, excessive salivation, a burning sensation

in the epigastrium, and diarrhoea. Diarrhoea, due to inflammation of gastrointestinal
tract could be bloody in nature. In fact, the mucous membrane of the gastrointestinal 85
Public Nutrition tract is inflamed causing enteritis and gastritis. Signs of B-complex deficiency like
glossitis are very common in pellagra. The mouth is sore and the tongue is brilliant
or beef red in colour and swollen. Cheilosis and angular stomatitis are seen in niacin
deficiency, though these may, in part, be a result of a simultaneous riboflavin deficiency.
As described above, early neurological symptoms associated with pellagra include
anxiety, depression, and fatigue. Later symptoms include apathy, headache, dizziness,
irritability and tremors. In early cases the manifestations are psychoneurotic, later,
lesions affect the nerves. Dementia, where due to derangement of mental functions,
the patient suffers from insomnia, disorientation, confusion and even delirium. There
may be changes in electroencephalogram.
Box 4 summarizes the clinical manifestations of pellagra.
Box 4 Clinical Manifestations of Pellagra in Adults
Body System Typical Lesions

Skin Initial changes: temporary redness like that of sunburn
Hyper pigmentation and thickening of skin
Dark red or purplish eruptions followed by desquamation
Lesions are bilateral or symmetrical involving areas or
friction and exposure i.e. face, neck, hands and feet
Mouth Gingivitis, stomatitis and glossitis, tongue is swollen and
beefy red in colour
Gastrointestinal tract Diarrhoea
Central Nervous Progressive dementia with apprehension and confusion
System in the early stages progressing to severe derangement.
Let us now learn how pellagra is caused.

Causes
Pellagra is a diseases closely associated with poverty, a low standard of living and
poor environmental sanitation. The disease is associated with poorer communities
whose staple is either maize or jowar. Maize has low tryptophan content and
relatively low niacin content which, in addition, is in the bound form so that only
about 30% is bioavailable. Tryptophan, the amino acid, is a precursor of nicotinic
acid. You may recall studying in the Advance Nutrition Course (MFN-004) that 60
mg of tryptophan is equivalent to 1mg of nicotinic acid. The daily requirement of
niacin are thus affected by the quantity and quality of protein in the diet, particularly
the tryptophan content. In communities depending on jowar as staple, pellagra is
attributed to metabolic changes caused by excess of amino acid leucine. Pellagra is
also observed in alcoholics and those suffering from malabsorption.
Let us learn how pellagra can be treated.
Treatment
The patients with pellagra can be treated with a diet containing adequate amounts
of protein, amino acid tryptophan or niacin. Oral administration of 100-300 mg of
nicotinic acid every day is adequate except in cases with severe diarrhoea. Patients
should also receive other B-complex vitamins, particularly riboflavin and pyridoxine to
take care of neurological manifestations. The response to treatment is dramatic in the
case of mental symptoms, which show improvement in 2-3 days. Three to four
weeks’ treatment is required for curing skin changes. However, prevention is better
than cure. So, then let us study how we can prevent pellagra.
86
Prevention Nutritional Problems--II
Replacement of the jowar or maize with cereals containing good quality protein can
prevent pellagra. Development and propagation of strains of jowar that are low in
leucine could be one of the approach. In areas which are endemic to pellagra,
fortification of foods with niacin is another alternative. Fortunately, with changes in
the quality of diet, particularly reduction in the consumption of maize and jowar,
pellagra has been averted, to a large extent, in India.
Let us now learn about the deficiency of folic acid and Vitamin B12 deficiency. We
will study about the manifestations, cause, prevention and treatment of these
deficiencies.
4.2.4 Folic Acid and B12 Deficiency
Folic acid and vitamin B12 are essential for the synthesis of nucleic acids and amino
acids. In the recent past, folic acid is considered to be important to prevent neural
tube defects in foetus. In this context it is important for us to study about the
deficiency conditions associated with this vitamin. On the other hand nutritional
deficiency of B12 is rare. Let us review the symptoms, causes, prevention and
treatment of folic acid and Vitamin B12 deficiency.
Clinical Manifestations of Folic Acid and Vitamin B12 Deficiency
The deficiency of folic acid the water-soluble vitamin of B-complex group leads to
megaloblastic anaemia. Megaloblastic anaemia, you may recall studying earlier in
the Applied Physiology Course (MFN-001) in Unit 2, is a blood disorder characterized
by anaemia, with red blood cells that are larger than normal, usually resulting from
a deficiency of folic acid or of vitamin B. Though, not as common as iron deficiency
anaemia, folic acid deficiency is observed in as high as 40-50% of anaemia in
pregnant women. Both peripheral smears of blood and bone marrow show macrocytes
(larger RBC) as shown in Figure 4.3. The white cell count may also be less.
Figure 4.3: Large oversized red blood cells seen in megaloblastic anaemia
Vitamin B12 deficiency, on the other hand, leads to what is known as pernicious
anaemia, which is a type of megaloblastic anaemia, which could be considered as
genetic in nature. Pernicious anaemia is caused by a lack of intrinsic factor, a
substance needed to absorb vitamin B12 from the gastrointestinal tract. Vitamin B12,
in turn, is necessary for the formation of red blood cells. Inadequate vitamin B12
gradually affects sensory and motor nerves, causing neurological problems to develop
over time. Because vitamin B12 is needed by nerve cells and blood cells for them
to function properly, deficiency can cause a wide variety of symptoms, including
fatigue, shortness of breath, tingling sensations, difficulty in walking, and diarrhoea.
In adults, it may lead to peripheral neuritis and some psychotic changes. In children,
who are breastfed for prolonged periods, anaemia occurs as a result of dietary
deficiency of the vitamin. Growth retardation and mental apathy are some of the
manifestations.
Let us review what causes folic acid and B12 deficiency.
87
Public Nutrition Causes of Folic Acid and Vitamin B12 Deficiency
Dietary deficiency is the main reason for folic acid deficiency. Folic acid is available
in green leafy vegetables, liver, meat and pulses. However, considerable destruction
of the vitamin occurs during cooking. Its deficiency can occur when there is
impairment of absorption of folic acid like in pregnancy. Increased demands during
infancy due to growth and pregnancy, prolonged use of anticonvulsants, infections
and infestations may be important causes.
On the other hand, Vitamin B12 deficiency occurs due to the absence of intrinsic
factor in gastric mucosa. Intrinsic factor is a protein the body uses to absorb vitamin
B12. When gastric secretions do not have enough intrinsic factor, vitamin B12 is not
adequately absorbed, resulting in pernicious anaemia and other problems related to
low levels of vitamin B12. In addition to pernicious anaemia, other causes of vitamin
B12 deficiency include :
l Nutrition (since vitamin B12 is available only in animal foods, its deficiency is
possible in pure vegetarians i.e. vegans. In countries like India, the vitamin
appears to be derived mostly from faecal contamination of foods. Further poor
diet in infant or poor maternal nutrition during pregnancy can be a cause for
this deficiency)
l Infection (intestinal parasites, bacterial overgrowth)
l Gastrointestinal disease (stomach removal surgery, celiac disease (sprue), Crohn’s
disease)
l Drugs (neomycin, tuberculosis, treatment with para amino salicylic acid etc.)
l Metabolic disorders (methylmalonic aciduria, homocystinuria)
Let us next learn how these deficiencies can be prevented.
Prevention of Folic Acid and Vitamin B12 Deficiency
Supplementation with folic acid along with iron is one of the strategies being adopted
by the government to prevent and control anaemia due to folic acid deficiency. The
details of the programme, you may recall studying in Unit 3 earlier under the
micronutrient deficiencies  iron deficiency anaemia. The most rational approach to
prevent folic acid deficiency is to improve the daily diets by ensuring foods rich in
folic acid like green leafy vegetables, pulses and meat products. As for vitamin B12
deficiency, consumption of as little as 250 ml of milk every day would suffice to
prevent vitamin B12 deficiency.
Let us get to know about the deficiency of Vitamin C i.e. scurvy. We will discuss
about manifestations, causes, treatment and prevention here as we have done for
the other deficiency diseases above.
4.2.5 Scurvy
Scurvy was endemic during the Middle Ages causing damage to armies in Europe
and is, perhaps, one of the oldest diseases known to the humanity. It was considered
to be due to poor intakes of fresh foods. What are the characteristic features of
scurvy? Let us look at the features of scurvy next.
Manifestations
The characteristic clinical features of scurvy are spongy-bleeding gums (refer to
Figure 4.4(a), petechial haemorrhages, joint pains, fatigue, depression and tenderness
of bones. Common symptoms include pinpoint bleeding around hair follicles, along
the gums, and under the nails, as seen in Figure 4.4 (b). In neonates, vitamin C
deficiency is characterized by tenderness of lower extremities and haemorrhages in
88 costochondral cartilages, fever and irritability. Bleeding into muscles and nail beds is
observed. Radiological evaluation (X ray) confirms the diagnosis. Vitamin C deficiency Nutritional Problems--II
can lead to reduced ability to fight infections, reduced capacity for healing and mild
anaemia.
(a) Bleeding gums (b) Pinpoint bleeding under the nails
Figure 4.4: Manifestations of vitamin C deficiency
Having studied about the clinical manifestations of scurvy let us next get to know
what causes scurvy.
Causes of Scurvy
The deficiency of ascorbic acid is not as common as it used to be before. However,
vitamin C is heat-labile and water-soluble. Hence, faulty cooking practices, inadequate
consumption of fresh vegetables and fruits are the major reasons for vitamin C
deficiency. Citrus fruits, amla, guava and green leafy vegetables are good sources of
ascorbic acid. You would note from the discussion that there are common causes of
vitamin B complex and Vitamin C deficiency. These are listed in the Box 5.
Box 5 Causes of Vitamin B-complex and C deficiency

l Inadequate intakes
l Faulty cooking practices
l Malabsorption
l Prolonged use of drugs
l Alcoholism
l Increased demands
Let us learn how we can treat scurvy.

Treatment
Scurvy in children is cured by 10-25 mg of vitamin C, 2-3 times a day. It may take
2-3 weeks for complete treatment. Let us review how we can prevent scurvy.
Prevention
Scurvy is no more a public health problem in India. However, the role of vitamin C
in promoting iron absorption and as a potent antioxidant has been recognized. Regular
intake of fresh vegetables and fruits is the most rational and sustainable method of
preventing vitamin C deficiency. The common sources of vitamin C that are readily
available are: citrus fruits such as lemon, orange, guava, amla and tomato.
89
Public Nutrition Let us learn about the deficiency of vitamin D i.e. Rickets and Osteomalacia. Here
again,we will learn about manifestations, causes, treatment and prevention of vitamin
D deficiency.
4.2.6 Rickets and Osteomalacia

Rickets has been known to be a nutritional disease for over 100 years and cod liver
oil was known to prevent it. In India, rickets is not seen in community surveys,
although it is seen in hospitals. Let us learn about the symptoms of rickets and
osteomalacia.
Manifestations
Rickets occurs generally in growing children, who are not adequately exposed to
sunlight. The signs and symptoms of the deficiency are mainly due to inadequate
mineralization. While in the children it is known as rickets, in adults it is referred
to as osteomalacia. The bones are soft and easily bend and therefore, deformities
are common. In growing children, swollen and painful growing ends of long bones
(particularly visible and palpable at the ribs, wrists and ankles) characterize it. The
bones cannot stand even normal mechanical stress. As a result, when the children
start walking, they develop bowlegs and knock-knees. In the ribs, at costochondral
junction, swellings, which appear like rosary, referred to as rachitic rosary is found.
Figure 4.5 illustrates some of these manifestations of vitamin D deficiency,
(a) Knock knees (b) swelling of the wrist (c) Rib beading (rachitic
rosary)
Figure 4.5: Manifestations of vitamin D deficiency
In adults, osteomalacia manifests due to undermineralization and excessive bone loss,

resulting in the extreme cases, fractures. Osteomalacia occurs due to calcium depletion
in women of childbearing age due to multiple pregnancies and particularly among
those observing purdah, like in Muslim communities. The women may complain of
pain in bones of lower extremities, back ache and difficulty in walking. Due to
softness of bones, the bones become soft and can easily bend leading to bony
deformities. Muscular hypotonia (low muscle tone), tetany and convulsions due to
hypocalcemia occurs. Let us see what causes it.
Causes
It is due to inadequacy of vitamin D, considered as a prohormone. It gives rise to
the hormone 1, 25-dihydroxy D3, the primary function of which is to regulate serum
calcium. One of the main causes is inadequate exposure to sun. Infants who are
solely breastfed and not exposed to adequate sunlight and premature infants are
more prone to rickets. Osteomalacia can occur due to some gastrointestinal
disturbances and chronic renal diseases where there may be impairment of absorption
90 of calcium and synthesis of vitamin D.
Let us learn about the treatment of rickets and osteomalacia. Nutritional Problems--II
Treatment
Treatment of both rickets and osteomalacia requires administration of vitamin D and
ensuring adequate calcium intake. Let us know about the prevention.
Prevention
Adequate exposure to sunlight is absolutely essential for prevention of rickets and
osteomalacia. Simultaneously, it should be ensured that the diets provide adequate
amounts of calcium daily. The awareness among the communities should be increased
so that the diets contain foods, which provide calcium. Among the foods, milk is the
best food.
We will now learn about fluorosis and lathyrism in the next section. But first let us
recall what we have learnt so far.

1. Match the following:
Column A Column B
Vitamins Clinical Deficiency
1. Thiamine (B1) a) Rickets/Osteomalacia
2. Riboflavin (B2) b) Scurvy
3. Niacin c) Beriberi
4. Folic Acid d) Megaloblastic anaemia
5. Ascorbic acid e) Pellagra
6. Vitamin D f) Ariboflavinosis
2. List causes of:

a. Thiamine deficiency
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
b. Niacin deficiency
.................................................................................................................
.................................................................................................................
3. How can we prevent:

a. Folic acid deficiency
.................................................................................................................
.................................................................................................................
b. Vitamin D deficiency
.................................................................................................................
.................................................................................................................
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Public Nutrition
4.3 FLUOROSIS
Fluorosis, a chronic public health problem, is caused by excess intake of fluoride
through drinking water or food products or industrial pollutants over a long period.
Fluorosis is endemic in several parts of India like in the States of Uttar Pradesh,
Madhya Pradesh, Bihar. An estimated 11.5 million people are at risk and 62 million
people in India suffer from dental skeletal and non-skeletal flourosis. (NPPCF,
2016). What is fluorosis? It is a crippling and painful bone disease caused due
to consumption of excessive fluoride in water. According to scientific surveys,
skeletal fluorosis in India occurs when the fluoride concentration in water exceeds
1 part per million (ppm), and has been found to occur in communities with only 0.7
part per million. Interesting isn’t it! Let us look at the manisfestions of fluorosis.
Manifestations
Fluorosis manifests mainly as dental fluorosis, skeletal and non-skeletal fluorosis.
A review of these manifestations follows.
Dental Fluorosis: It occurs in children of both the sexes exposed to high fluoride
intake even before the dental mineralization is complete. It is characterized by
mottling of teeth, which appears as yellowish or brown streaks or spots, as can be
seen in Figure 4.6, particularly evident on the incisors. Sometimes, pitting (deeper
depressions) may occur on these teeth. Dental mottling is irreversible and is confined
to permanent teeth.
Figure 4.6: Dental Fluorosis
Skeletal Fluorosis: This is a bone disease caused by an excessive consumption of

fluoride. This is a slowly progressing condition and is not as clinically obvious as
dental fluorosis. The clinical features include joint pains, musculoskeletal dysfunction,
restricted mobility of spine and deformities of flexion type. The disorder starts with
vague nonspecific symptoms like pain in the joints, followed by stiffness and restriction
in the movements of spine. In the later stages there may be spinal deformities with
vertebral column becoming rigid with inability even to bend. In the recent past,
severe deformities known as genu valgum, an adult form of exaggerated knock-
knees has been described in endemic fluorotic areas. Experts suggest that crippling
skeletal fluorosis might occur in people who have ingested 10-20 mg of fluoride per
day for 10-20 years isn’t that alarming.
Non-Skeletal Fluorosis is an earlier manifestation of fluorosis seen as a gastro-
intestinal complaint etc. and may overlap with other diseases leading to misdiagnosis.
So, it is clear that fluorosis can affect young and old, men and women alike. Let
us then learn what causes fluorosis?
Causes
It is mainly due to very high content of fluorides in drinking water. Foods also
92 contribute significantly to fluoride content of the diet. Cereals and vegetables grown
in areas, which are endemic for fluorosis, contain higher amounts of fluoride. It is Nutritional Problems--II
reported that as much as 85% of the total fluoride intake is contributed by food.
Poor socioeconomic conditions and poor nutritional status may be associated with
fluorosis. Remember, fluoride can enter the body through drinking water, food,
toothpaste, mouth rinses and other dental products; drugs, and fluoride dust and
fumes from industries using fluoride containing salt and or hydrofluoric acid.
Let us now learn how we can prevent fluorosis.
Prevention
Ensuring that the drinking water has safe levels of (below 1 ppm) fluoride is the
best solution for controlling endemic fluorosis. Supply of water from rivers, dams,
canals and other sources of surface water is one of the methods adopted extensively
in areas, which are highly endemic. Another method is defluoridation (removal of
fluoride) of water by appropriate treatment of water. Several domestic methods are
suggested of which ‘Nalgonda technique’ and ‘Prashanti Technique’ are perhaps
simple and acceptable. While in the first method, lime and alum are added to water,
in the latter, activated alumina is used for passing water. Commercial defluoridation
is very expensive and is not practiced frequently. Education of communities to avoid
use of fluoride rich toothpastes, pesticides and fertilizers is important.
Finally, we move on to lathyrism.
4.4 LATHYRISM
What is lathyrism? You may recall studying about lathyrism in the Food Microbiology
and Safety Course (MFN-003) in Unit 7. Certain foods of Leguminaceae family
contain toxic amino acids, which pose serious health problems to mankind. Of them,
Lathyrus sativus (Kesari dhal) could be considered to be of public health
significance, in view of the serious crippling consequences due to continued
consumption of the pulse. The disease attributed to the consumption of this food is
referred to as lathyrism. Lathyrism, causes upper motor neuron degenerative disease,
leading to paralysis. Let us elaborate on symptoms of lathyrism.
Manifestations
The disease, seen among young adults in their most productive age, is insidious in
nature. It is characterized by altered gait, severe pain in the lumbar region of the
back, spasticity and paralysis. The earliest symptom is muscular spasms in the calf.
This is followed by stiffness and heaviness in limbs, muscular cramps, involuntary
tremors and ultimately typical stiff legged scissors gait. In the initial stages the
affected may be able to walk with the help of a single stick, which progresses to
two-stick stage and finally to crawling stage.
Let us learn what causes it.
Causes
The disease is caused due to exclusive consumption of kesari dhal over a long
period of time. The pulse contains a toxic amino acid known as beta-oxalyl amino
alanine or BOAA, which is a neurotoxin. In parts of Madhya Pradesh and contiguous
areas of Uttar Pradesh and Bihar, the labourers receive kesari dhal as wages,
particularly during drought seasons. L. sativus, which is grown as a mixed crop
along with wheat, being a hardy, survives despite damage to wheat crop. As a
result, the labourers solely depend on kesari dhal rotis for their survival, ultimately
suffering from the crippling condition. Let us see how we can prevent it.
Prevention
In most of India, gradually, cultivation of kesari dhal crops has declined over time
because of ban on its sale under Prevention of Food Adulteration Act. In addition, 93
Public Nutrition distribution of cereals at affordable rates through public distribution system has
helped in total dependence of the labour on kesari dhal. In the long run, development
of genetically modified low toxin levels of L. sativus would help not only in controlling
lathyrism but also in improving the availability of pulses. The toxin, being water
soluble, can be removed by parboiling. At the domestic level, steeping of the pulse
in boiled water and drying the same, removes most of the toxin. Education of the
communities to adopt such simple household methods would help in the control of
the unreversible paralytic condition.
With this, we end our study of the nutritional problems which are of concern and
can be of concern to us. Do answer the questions given here under the check your
progress exercise 2 and check you understanding about the nutritional problems
learnt in the last section.
1. List key manifestations and causes of fluorosis.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
2. How can we prevent fluorosis?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
3. What is the cause of lathyrism?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
4. List the three stages of lathyrism.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
4.5 LET US SUM UP

In this unit we learnt that there are other nutritional problems which may occur in
large number of people in developing countries either due to poor diet or other
environmental conditions. These are deficiency of some B-complex vitamins like
thiamine, riboflavin, niacin, folic acid and B12 as well as deficiency of vitamin C and
vitamin D. Fluorosis and lathyrism although not vitamin deficiency, cause many
complications in the human body. Next, we studied that most of Vitamin B- complex
deficiencies and Vitamin C deficiencies are due to faulty cooking practices,
malabsorption, prolonged use of drugs, alchoholism and increased demands due to
physiological changes in the body. Another nutritional disorder is fluorosis which is
endemic in several parts of India like in the States of Andhra Pradesh, Gujarat,
94 Karnataka, Maharashtra, Punjab, Rajasthan and Tamil Nadu. It is due to consumption
of excessive fluoride in water. Finally, we read about Lathyrism. Lathyrism is a Nutritional Problems--II
disease which is caused due to exclusive consumption of kesari dhal over a long
period. It can lead to paralysis. In India, there is a ban on the sale of kesari dhal
under Prevention of Food Adulteration Act.
4.6 GLOSSARY
Cyanosis : bluish discolouration of skin due to the presence of oxygen-
deficit blood.
Delirium : disordered state of mind involving incoherent speech and
excitement.
Hyperaestheisa : a state of enalted or morbidity increased sensibility of the body
or a part of it.
Neurotoxin : any poison that acts on nervous system.
Palpitations : rapid strong or irregular heart beat.

EXCERCISES
1. 1 c, 2 f, 3 e, 4 d, 5 b, 6 a
2. a. Thiamine deficiency is caused when people consume highly polished rice
and adopt improper cooking practices such as throwing away the excess
water after cooking the rice.
b. Niacin deficiency is generally found in poorer communities where people
use either maize or jowar as staple food. Pellagra is also observed in
alcoholics and those suffering from malabsorption.
3. a. Folic acid deficiency can be prevented by supplementing the diet with folic
acid along with iron tablets. This is one of the strategies being adopted by
the governments to prevent and control anaemia due to folic acid deficiency.
b. Vitamin D deficiency can be prevented through adequate exposure to sun
light daily and by providing recommended amount of calcium in diet daily.
1. Fluorosis manifests mainly as dental fluorosis and skeletal fluorosis. It is caused
mainly due to very high content of fluoride in drinking water. Foods also contribute
significantly to fluoride content of the diet.
2. Fluorosis can be prevented by ensuring that the drinking water has safe levels
of below 1 ppm fluoride.
3. Lathyrism is a disease which is caused due to exclusive consumption of Kesari
dhal over a long period.
4. Three stages of lathyrism are: i) Able to walk with the help of one stick,
ii) Only possible to stand and walk with two sticks, and iii) Paralytic crawling
stage.
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Public Nutrition
UNIT 5 HEALTH ECONOMICS AND
ECONOMICS OF MALNUTRITION
Structure
5.1 Introduction
5.2 Health Economics
5.3 Malnutrition and its Economic Consequences
5.3.1 Causes of Malnutrition
5.3.2 Consequences of Malnutrition
5.3.3 Indicators of Nutrition
5.3.4 Interventions in Malnutrition and Government Expenditure on Interventions
5.4 Economics in Nutrition

5.4.1 Food Security
5.4.2 Food Production
5.4.3 Food Pricing
5.5 Economic Evaluation of Malnutrition

5.6 Let Us Sum Up
5.7 Glossary
5.1 INTRODUCTION
In the earlier units on nutritional problems, we learnt that there are many causes of
malnutrition, socioeconomic cause, being one of them. When economic condition of
the people is poor, they have inadequate access to food and health services, which
contributes to poor nutritional status. We also studied that some micronutrient
deficiencies like anaemia and iodine deficiency compromise on mental and physical
work capacity, which leads to lowered productivity of individuals at work. This, in
turn, leads to reduction in wages earned and poor economic condition. So, we can
see that poor economic status contributes to malnutrition and malnutrition contributes
to poor economic status. There is a mutual cause and effect relationship between
malnutrition and economic status. In this unit, we are going to explore this relationship
in detail. We are going to study about economics of health and economic consequences
of malnutrition. Since nutrition is a determinant of health, we will discuss about
nutrition economics under which we will focus our discussion on food resources and
their efficient utilization to improve nutritional status of individuals. At the end, we will
explore the concept of economic evaluation of health interventions.
Objectives
l explain the concept of health economics;
l describe economic consequences of malnutrition;
l discuss economics of nutrition;
l explain the food security and issues related to food production; and
96 l enumerate the concept of economic evaluation of malnutrition.

Health Economics
5.2 HEALTH ECONOMICS and Economics of
Malnutrition
Health economics concentrates on application of the principles and rules of economics
in the sphere of health. In broad terms, it includes analysis and evaluation of health
policy and the health system from an economic perspective. In particular, it includes
health system planning, market mechanisms, demand and supply of health care,
economic evaluation of individual diagnostic and therapeutic procedures,
determinants of health and its evaluation, and evaluation of the performance of
health care systems in terms of equity and efficiency. The process involves
calculating the cost incurred to tackle the problem and the consequences, which arise
because of the problem. A decision is then taken in where to invest so that maximum
benefits are achieved with the existing resources. In general the costs and consequences
from a health perspective are given in Table 5.1. It shows various direct, indirect
and tangible costs involved in managing the problems. It also shows the consequences
like morbidity, mortality and pain suffering as a result of the occurrence of problems.
Table 5.1: Cost of managing health problems and consequences
Cost of Managing the Health Consequences of Health Problems

Problems
l Direct l Physical functioning
-- Capital-land, -- Morbidity, and Mortality
building -- Disability
-- Operating-staff, l Resources use
overheads -- Cost averted by health care system in
l Indirect the form of treatment
-- Production loss -- Productivity loss averted
-- Transportation l Social and emotional functioning
-- Boarding & lodging -- Pain, Suffering, Grief
l Intangible l Changes in quality of life
-- Pain, Suffering, Grief l Friends and Family
Analysis and evaluation of health policy and system is important because it helps us
to plan the targeting of health resources required for alleviating the problems. We
already know that there are multiple causes of malnutrition; so just focusing on health
resources will not help solve the problems. Since nutrition is a determinant of health,
focus on food resources becomes very critical. We will discuss food resources in
detail under nutrition economics in Section 5.4 later. Now let us review the economics
aspects of causes and consequences of malnutrition.
5.3 MALNUTRITION AND ITS ECONOMIC

CONSEQUENCES
What is malnutrition? Malnutrition can be defined as a pathological condition
resulting from a relative or absolute deficiency or excess of one or more of the
essential nutrients. From a nutritional standpoint, the condition can fall under the
following 4 categories as shown in Table 5.2. These categories are undernutrition,
overnutrition, imbalance of nutrients and specific deficiencies of nutrients.
Table 5.2: Classification of malnutrition based on nutrient intake
S. No. Type Nutrient Intake
1. Undernutrition Inadequate
2. Overnutrition Excess
3. Imbalance Disproportionate
4. Specific deficiency Relative or absolute lack of
an individual nutrient
97
Public Nutrition Let us now understand the causes of malnutrition before we explain the consequences
of malnutrition. We have read about causes of malnutrition in Unit 3. We will recapitulate
these now.
5.3.1 Causes of Malnutrition
You may recall studying about the causes of malnutrition earlier in Unit 5. The causes
of malnutrition are classified as immediate (individual level), underlying (household or
family level) and basic (societal level) causes as highlighted in Figure 5.1 whereby
factors at one level influence other levels. Each of these factors is essential, but is not
sufficient in itself to achieve nutrition security. One of the important factors, which act
at the individual level, is the socioeconomic status. Other factors at the individual and
household level include availability or accessibility of food, poor knowledge about
balanced diet etc. You would note here that poverty affects almost every factor acting at
the individual level as shown in Figure 5.1. For example, you can see in Figure 5.1 that
when people do not have enough money, they may not be able to purchase enough food
for their families and/or access health services which leads to malnutrition. The problems
at the societal level include that of educational status, performance of agricultural sector,
policies related to food imports contributing to malnutrition.
Malnutrition and its

Outcomes
consequences
Inadequate/
Inappropriate Disease
Immediate
dietary intake
causes
POVERTY
Insufficient
Inadequate health services
access to food and unhealthy
environment Underlying
Inadequate
causes
education
Formal and Non-

formal institutions
Political and ideological Basic causes

superstructure
Economic structure
Potential
resources
Figure 5.1: Malnutrition and its causes
You must have heard many times that cause of hunger is poverty. However, hunger
also leads to poverty. So, poverty and hunger have mutual cause and effect relationship.
That is, poverty leads to hunger and hunger leads to poverty. Let us see how.
Poverty and hunger  mutually causes, devastating effects
Measures of food deprivation, nutrition and poverty are strongly correlated. Countries
with a high prevalence of undernourishment also have high prevalence of stunted and
underweight children. In these countries, a high percentage of the population lives in
conditions of extreme poverty. In countries where a high proportion of the population
is undernourished, a comparably high proportion struggles to survive on less than US$1
per day. While poverty is undoubtedly a cause of hunger, hunger can also be a cause
of poverty. Hunger often deprives impoverished people of the one valuable resource
they can call their own: the strength and skill to work productively. Numerous studies
have confirmed that hunger seriously impairs the ability of the poor to develop their
98 skills and reduces the productivity of their labour.
Hunger in childhood impairs mental and physical growth, crippling the capacity to learn Health Economics
and earn. Evidence from household food surveys in developing countries shows that and Economics of
Malnutrition
adults with smaller and slighter body frames caused by undernourishment earn lower
wages in jobs involving physical labour. Other studies have found that a 1 percent
increase in the Body Mass Index (BMI, a measure of weight over height square) is
associated with an increase of more than 2 percent in wages for those toward the
lower end of the BMI range.
Micronutrient deficiencies can also reduce work capacity. Surveys suggest that iron
deficiency anaemia reduces productivity of manual labourers by up to 17 percent. As
a result, hungry and malnourished adults earn lower wages. And they are frequently
unable to work as many hours or years as well-nourished people, as they fall sick more
often and have shorter life spans. This then brings us to the issue of economic
consequences of malnutrition. We have read about consequences of malnutrition in
Unit 3. We will recapitulate this here and then study about economic consequences of
malnutrition. Let us first recapitulate consequences of malnutrition.
5.3.2 Consequences of Malnutrition

Malnutrition manifests itself in terms of illness and death in all age groups. Children,
pregnant women, nursing mothers and elderly are particularly vulnerable to the effects
of malnutrition. Let us closely look at the effects of Malnutrition in children.
Malnutrition contributes to more than half of child deaths worldwide.
WHO states that fifty-four percent of deaths among preschool (<5 years) children in
the developing world are due to the underlying effects of malnutrition on disease, but
conventional methods of classifying deaths by cause have misleadingly attributed only
about five percent of child deaths to malnutrition.
The risk of death rises as the grade of malnourishment increases among
children from mild to moderate to severely malnourished.
It was previously thought that only severely malnourished children were at increased
risk of dying, but recent studies show that even mild and moderately malnourished
children are at increased risk of death because of their poor nutritional status. On an
average, a child who is severely underweight is 8.4 times more likely to die from
infectious diseases than a well-nourished child. Children who are moderately underweight
and mildly underweight are 4.6 and 2.5 times, respectively more likely to die than well-
nourished children. It is estimated that the vast majority (35%) of all malnutrition
related deaths worldwide occur in children who are underweight. Programmes directed
only at treating severe malnutrition, therefore, will have only a minor impact on child
mortality rates.
The synergistic contribution of malnutrition to child mortality is consistent

across populations and can be estimated at the country level from weight-
for-age prevalence data.
Analysis show that the quantitative relationship between malnutrition and mortality is
remarkably consistent across various populations representing diverse ecological, disease
and cultural environments. The percentage of all malnutrition-related deaths that occur
in mildly and moderately malnourished children can also be estimated from weight-for-
age prevalence data.
As discussed earlier, malnutrition affects vulnerable population across all age groups.
Table 5.3 summarizes consequences of malnutrition in the other vulnerable population
like pregnant and lactating mothers, adults and older adults.
99
Public Nutrition
Table 5.3: Consequences of malnutrition
Common Nutritional Disorders Consequences
Pregnant and lactating mothers
PEM, IDD, VAD, IDA, Insufficient weight gain in pregnancy,

Folate deficiency, Calcium maternal anaemia, maternal mortality,
deficiency increased risk of infection, night
blindness, low birth weight leading to
high risk of infant death
Intergenerational cycle
PEM, IDD, VAD, IDA, Deficiencies passed on to the child who

Folate deficiency, Calcium deficiency may then pass them on to the
subsequent generation
Adults
PEM, obesity, IDA and diet related Thinness, Lethargy, Obesity, Heart
diseases disease, Diabetes, Cancer, Hypertension
Anaemia
Elderly
PEM, IDA, Obesity, Osteoporosis, Diet Obesity, Diabetes, Cancer, Spine and
related diseases Hip Fractures, Anaemia and Thinness
The discussion above focussed on the consequences of malnutrition across pregnant

and lactating women, children, adults and older adults. We may conclude that when
people have illnesses as a result of malnutrition, it compromises on their work productivity.
Let us now study effects of malnutrition on economic productivity of people or, in
other words, economic consequences of malnutrition.
* Economic consequences of malnutrition
Figure 5.2 explains the economic consequences of malnutrition. You would note from
the Figure 5.2 that the economic productivity of the individual, influences the household
income, which influences the household food availability and food allocation in the
family. When household real income falls as a result of low economic productivity,
families have less food available for different members of the families. Thus food
consumption for the different members of the family falls. In our culture, it is mostly
the women and the children who suffer the most as a result of poor availability of food
at home compared with other members of the family. Poor food consumption contributes
to low nutritional status of the family members especially the other and the child.
Mothers with poor nutritional status have low capacity to take care of the child, such
ignorance to the child leads to long term consequences in terms of growth, cognitive
capabilities, morbidities and mortality etc. This also results in loss of productivity in
school. For adults, poor nutritional status leads to reduced stamina and endurance and
low physical capacity at work, thus contributing to reduced economic productivity. So
this loss of productivity influences economic status of the family that can further
deteriorate nutritional status. This vicious cycle persists unless strong steps are taken
100 to increase the household real income and improve the nutritional status.
Health Economics
and Economics of
Malnutrition
Economic Mortality
Household
Individual
Real Income
Days Lost from Schooling

Morbidity School Productivity
Decision Making
in Household
Child Caring
Practices
Household
Food Cognitive Days Lost from
Availability Function Work
Food Consumption
Nutritional
of Mother
Status of Child Growth
Food Allocation Individual
in Household Physical Economic
Food Consumption of Capacity Productivity
Child
Stamina &
Endurance
Current
Current Food Consumption of Nutritional
Individual Household Members Status
Figure 5.2: Economic consequences of Malnutrition
We can now conclude that loss in the productivity of individuals lead to a loss in
productivity of the nation as a whole and so nations cannot progress. This brings us
to the issue that we need to assess and analyze the situation and plan and implement
interventions to improve the nutrition situation. For doing this, we need to come up with
some indicators which can help us track changes in the situation as we move towards
our goals. We will now study about the “indicators” in detail.
5.3.3 Indicators of Nutrition

We will begin our study on this topic by first understanding what we mean by an
indicator. An indicator is a “specific and measurable statistical construct for
monitoring progress towards a goal”. Indicators are used to monitor a given
characteristic (e.g. health status) of a population or to make comparisons with a
different population or the same population at a different point in time. Indicators are
therefore specific measures for assessing progress towards goals. The indicators may
fall under the following categories:-
1. Macro indicators for sector-wide monitoring and evaluation,
2. Meso indicators for regional or cross-agency policy monitoring and evaluation,

and
3. Micro indicators for agency programme monitoring and evaluation.
Figure 5.3 depicts the three types of indicators.

101
Public Nutrition Indicator types
Micro Strategic
General
Level
of Meso
detail
Specific
Micro Performance
Figure 5.3: Types of indicators
As you may have noticed in Figure 5.3, the indicators may fall under three categories:
Macro indicators are used at strategic levels while micro indicators are used at
performance levels. From the previous sections it is clear that many factors contribute
either directly or indirectly to the nutritional status of individuals. So, choosing an
indicator will depend on what we want to analyze. We can have indicators related to
1) government policies, 2) individual information on food/income etc, 3) food and
nutrient intake 4) nutritional status, and 5) health status. A few of the indicators are
enumerated below:
1. Indicators related to Government policies
a. Nutrition policy
b. Nutrition interventions: feeding programmes (e.g. Mid day meals at school)
c. Percent free school meals (eligibility, uptake): is this a marker of nutritional
health or a marker of social or health inequalities?
d. Food availability, e.g. foods stocked in shops used: range, availability
e. Food accessibility
i. Food prices, e.g. relative cost of healthier food, money for food, shopping
capacity, domestic storage capacity etc
f. Food security - International and National
g. Food stocks - e.g. amount of emergency food supplies
h. Food subsidies
i. Food budget standards
2. Indicators at the individual level : Number of individuals who have gone
hungry through lack of personal food supply, amount of expenditure on food,
percent of disposable income spent on food and cost of 1 kcal etc. are some of
the indicators that can be used at individual level.
3. Food and nutrient intake
a. Direct: national, regional, household and individual
b. Dietary diversity (may be different within country compared with between
countries)
c. Food balance sheets
4. Nutritional status
102 Biomarkers, anthropometry and energy balance
5. Health status Health Economics
and Economics of
a. Morbidity and mortality rates Malnutrition
b. Macronutrients and micronutrient deficiencies

Having looked at some of the indicators, let us now review some of the interventions
in malnutrition.
5.3.4 Interventions in Malnutrition and Government Expenditure on
Interventions
We have studied about the causes of malnutrition at various levels. Similarly interventions
for malnutrition should be carried out at various levels. There are several interventions
aimed to reduce malnutrition. A detailed discussion on these interventions strategies is
presented in Unit 12 later in this course. Here, we will familiarize you with some
government programmes aimed to reduce malnutrition in vulnerable groups. Table 5.4
gives a list of various government programmes and their beneficiaries. Some of these
have already been described in Unit 3 and 4 on nutritional problems. As you move on
to Unit 10 later in this course, you will find that each of these programmes has specific
goals and objectives for e.g. National nutritional anaemia control programme is aimed
towards eliminating iron deficiency anaemia and so on.
Table 5.4: Review of Existing Programmes/Schemes

Target Group Schemes
Pregnant and Integrated Child Development Scheme (ICDS),
Lactating Mothers RMNCH+A, National Health Mission (NHM), Janani
Suraksha Yojana (JSY),
Pradhan Mantri Matru VandanaYojana (PMMVY),
National Nutrition Anaemia Control Programme (NNACP)
Children 0-3 ICDS, RMNCH+A, NHM, Rajiv Gandhi National Crechê
Scheme, National Prophylaxis Against Nutritional Blindness
due toVitamin A Deficiency (VAD)
Children 3-6 ICDS, RMNCH+A, NHM, Rajiv Gandhi National Crechê
Scheme, Total Sanitation Campaign (TSC), National Rural
Drinking Water Programme (NRDWP)
School going Mid Day Meals (MDM), Sarva Shiksha Abhiyan (SSA)
children 6-14
Adolescent Girls Rajiv Gandhi Scheme for the Empowerment of Adolescent
11-18 Girls (RGSEAG), Kishori Shakti Yojana
Adults Mahatma Gandhi National Rural Employment Generation
Scheme (MGNREGS), Skill Development Mission, Women
Welfare and Support, Programme, Adult Literacy
Programme, TPDS, Antoyodya Anna Yoajana (AAY),
Rashtriya Krishi Vikas Yojana, Food Security Mission, Safe
Drinking Water and Sanitation Programmes, National
Horticulture Mission, National Iodine Deficiency Disorders
Contol Programme (NIDDCP), Nutrition Education and
Extension, Bharat Nirman, Rashtriya Swasthya Bima Yojana.
103
Public Nutrition A detailed discussion of each of these programmes is provided in Unit 10. It is
important for you to know that our government including the states spend a large
amount of money on these programmes to improve nutrition situation in India. We will
now review how much money the government spends and which are the major
programmes on which most of the money is spent in order to improve the nutrition
status of people.
Total Government Spending on Nutrition
Total government spending on nutrition covers what the Government of India and
State Government spend on nutrition programmes. Experts have analyzed information
on the nutrition spending on major direct nutrition programmes and indirect nutrition
programmes. Direct nutrition programmes include short term measures to achieve
national nutrition goals. Indirect nutrition programme include long term measures to
achieve national nutrition goals. Major direct nutrition programmes for which financial
information has been analyzed are Integrated Child Development Services Programme
(ICDS), the National Midday Meals Programme (NMMP) and some micronutrient
programmes. Indirect nutrition programmes include Public Distribution System (PDS)
and Employment Generation Schemes.
We will present you with the analysis for average annual total government spending
on direct and indirect nutrition programmes available for the period 2018-2019. As per
the Union budget (2018-19) government spend an annual amount of about Rs. 23139.28
Cr. on the direct and indirect nutrition programmes during 2018-2019. Of which Rs.
23088.28 Cr. was spent on direct nutrition programmes and Rs. 51,00 Cr. was spent
on indirect nutrition programmes i.e. PDS. Thus, India spends a considerably larger
amount on indirect nutrition programmes, even if only the cereal subsidy component
of PDS and the food grain component of the centrally-funded employment programmes
are included.
Figure 5.4 provides a rough estimate of the average expenditure on these programmes
for the period 1995 to 1998. Also under direct nutrition programmes, spending on
ICDS was the highest (67%) followed by NMMP (30%) and micronutrient and other
programmes (3%).Under the indirect nutrition programmes, spending on PDS was
99% followed by employment assurance schemes (1%).
Direct Nutrition Programmes Indirect Nutrition Programmes

Note: ICDS costs include GOI and state-financed supplementary food expenditures; NNMP costs are
all GOI expenditures; Micronutrient and Other Programme costs include GOI expenditures on National
Iodine Deficiency Disorders Control Programme plus 5 percent of the Department of Family Welfare
budget to cover the Iron and Vitamin A distribution programmes; PDS costs are the total cereal subsidy
and EAS/JRY costs are for the food grains provided.
Figure 5.4: Average Annual Total Government Spending on Direct and Indirect Nutrition
Programmes, 1995-1998
Sources: Central Government expenditure budgets, Departmental Budgets and Economic Survey,
1997-98.
104
India spends far less on nutrition programmes than what is needed to reduce the extent Health Economics
of malnutrition among children under five years of age and pregnant and lactating and Economics of
Malnutrition
women. We consider the nutrition expenditure as a percentage of gross national product
(GNP) then, from 1985 to 1990, the average annual expenditure by the states and GOI
on direct nutrition programmes (mainly ICDS and NMMP) amounted to only 0.15
percent of gross national product (GNP). Government spending on direct nutrition
programmes increased in the 1990s, as a result of the expansion of ICDS and of the
NMMP in 1995 and amounted to about 0.19 percent of GNP in 1998. Currently around
0.9 per cent of GNP is spend on direct nutrition programmes. This is still less when
compared with other developing countries. For example, Sri Lanka, a country recognized
to have achieved considerable success in reducing the level of malnutrition, spent about
1 percent of its GNP on direct nutrition programmes during the mid 1980,s (World
Bank, 1993).
Recently, National Nutrition Mission (NNM) has been set up with a three year budget of
Rs. 9046.17 crore commencing from 2017-18. The NNM is a comprehensive approach
towards raising nutrition level in the country on a war footing. It will comprise mapping of
various Schemes contributing towards addressing malnutrition, including a very robust
convergence mechanism. NNM targets to reduce stunting, undernutrition, anaemia (among
young children, women and adolescent girls) and reduce low birth weight by 2%, 2%,
3% and 2% per annum, respectively. Although the target to reduce Stunting is at least 2%
p.a., Mission would strive to achieve reduction in Stunting from 38.4% (NFHS-4) to 25%
by 2022 (Mission 25 by 2022).
The Centre for Budget and Governance Accountability (CBGA) estimated that 25,600
crore rupees (3.9 billion USD) have been budgeted for nutrition specific interventions
through centrally sponsor schemes (CSS) such as ICDS while 215,000 crore rupees (32
billion USD) have been budgeted for nutrition-sensitive interventions. Overall nutrition
allocation from the central Government has increased by 1.4% (2015-16 RE to 2016-17
RE). India still needs to increase its spending on nutrition programmes.
This brings us to the issue of food resources and how proper planning and targeting
of food resources can help in combating malnutrition. We will study about this under
the purview of economics of nutrition. Now let us answer the questions given in check
your progress exercise 1 and recapitulate what we have learnt so far.
1. What do you mean by health economics?
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2. Explain economic consequence of malnutrition.
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3. Enumerate on the government spending on major direct and in direct nutrition
programmes.
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105
Public Nutrition
5.4 ECONOMICS IN NUTRITION
We mentioned earlier that nutritional problems affect the productivity of the individual,
which, in turn affects the productivity of the nation. This results in a great loss for the
nation. Many factors influence the nutritional state of an individual/community. e.g.
amount of food production, food storage, food pricing, subsidies, food distribution,
targeted public distribution, government policies etc. You would be surprised to know
that over the past three decades, the world has produced more grain per capita but
yet in any given year of that recent history, several million people have died from
hunger-related, causes. On any given day, perhaps a billion individuals are restricted
by their economic circumstances to consume less food than they would like, and
hundreds of millions have their growth and physical activity limited by inadequate food
consumption. Therefore, planning the food resources adequately can largely prevent
malnutrition. Ensuring equitable distribution of the available food resources is a
multisectoral challenge. The discipline of ‘nutritional economics’ hence tries to analyze
this relationship, so that the existing food resources can be used efficiently. The issues
that are covered by nutrition economics include:
1. Quantities of food commodities and their development in time (Food Production
Systems).
2. Prices of food commodities and their development in time.
3. Share of nutrition expenditures in total expenditures and their development in
time.
4. Development of total expenditures on food in stable prices.
5. Statement of the nutrition need according to the demographic structure of the
population.
6. Transfer of commodities into biological, nutritious values and their development in
time.
7. Construction of balances between the nutritious values and the nutrition needs.
8. International comparisons.
9. Construction of the recommended food/dietary allowances (RFA/RDA).
10. Estimates of the future demand of food dietary commodities.
The different aspects of nutrition economics and their interactions are illustrated in
Figure 5.5.
Environmental
Demand factors
Land
FOOD - Availability
Manpower Food
PRODUCTION - Accessibility
Equipment
Fertilizers, etc - Utilization
FOOD PRICES
Data FOOD
Prices SECURITY
ANALYSIS
Consumer
Policy Maker
PUBLIC
DISTRIBUTION
Policy Government Policy
SYSTEM
Import Export
106 Figure 5.5: Different aspects of nutrition economics and their interaction
As is evident food production is determined by demand for food and inputs like land, Health Economics
manpower and fertilizers etc. The data from food production is analyzed for policy and Economics of
Malnutrition
formulation. Food production also determines food prices which influences food security
of people.
In the following section, we will cover the first two, major aspects, of nutrition economics.
These aspects are:
1. Quantities of food commodities and their development in time (Food Production
Systems), and
2. Prices of food commodities and their development in time.
However, before we discuss these major aspects, we will first explain food security.
This is because, improving food security is a pre-requisite for combating malnutrition.
We have already learnt about the concept of food security in Unit 2, we will just
recapitulate this here.
5.4.1 Food Security

You were introduced to the concept of food security in Unit 2. Food security, we learnt,
is access by all people at all times to enough food for an active healthy life. In
1983, the FAO Committee on World Food Security, formalized the definition in 1983
and incorporated following three specific goals for food security which include:
1. ensuring adequacy of food supplies,
2. maximizing stability of supplies, and
3. securing access to available supplies to all who need them
Food security can be at the individual level, household level and at the community level.
In a given situation, food insecurity can result from the following three causes. These
are related to availability, accessibility and appropriate utilization of the food.
l Food availability: This refers to availability of necessary types of food in
sufficient quantity, to the individual. The sources may be from domestic
production, imports or donors. In other words, the food should be within the reach
of the individual.
l Food Access: Individuals have adequate incomes or other resources to purchase
or barter to obtain levels of appropriate foods needed to maintain consumption of
an adequate diet/nutrition level.
l Food utilization/consumption: This refers to how food is properly used. i.e.
food preparation, food handling, food storage, balanced diet, nutritional care of
vulnerable groups etc. Let us get familiarized with another term i.e. nutrition
security.
Nutrition security can be briefly defined as a balance between biological requirements
in energy and nutrients and the quantity and quality of food consumed. Nutritional
status is the outcome indicator of nutritional security. On the other hand, indicators for
food security are data related to number of undernourished, food production
data, consumption and distribution etc.
It is obvious that many factors contribute to food insecurity. In a developing country
like ours, it can be achieved only through sustained economic growth.
There are many initiatives, which have a potential to improve nutritional status
of the population? These include:
â Increasing food production-building buffer stocks
â Improving food distribution-building up the Public Distribution System (PDS) 107
Public Nutrition â Improving household food security through:
l improving purchasing power,
l distribution of food to the needy people, and
l direct or indirect food subsidy.
â Food supplementation to address special needs of the vulnerable groups - Children,
pregnant women and the elderly.
â Nutrition education
â The contributions from the health sector to tackle
l adverse health consequences of undernutrition,
l adverse effects of infection and unwanted fertility on the nutritional status,
and
l micronutrient deficiencies and their health consequences.
So we see that improving food security at various levels is one of the many initiatives
to improve nutritional status of the population. Many aspects of nutrition economics
contribute to improved food security. For example, if food production is increased,
there will be increased availability of food supply contributing to improved food security
as already illustrated in Figure 5.5. Let us now go back to two major aspects of
nutrition economics. 1) Quantities of food commodities and their development in time
(Food Production Systems), and 2) Prices of food commodities and their development
in time (Food Pricing).
We will begin our study with first aspect of nutrition economics i.e. Food production.
5.4.2 Food Production

We know that agriculture comprises the major source of food production. This is very
true in a country like ours where the majority of the population lives in the rural area
and farming is the primary mode of subsistence. Improvements in the agricultural
sector will hence result in overall improvements of the rural economy. This improvement
provides employment opportunities for a large population.
The extent of food production is influenced by various factors. The factors may
operate from the individual level (e.g. procurement of land, availability of manpower,
management of manpower, purchase of equipment etc.) to the policy level (food
pricing, subsidies, imports and exports. etc). Environmental factors also play an
important role. An understanding of the interaction of these factors is essential for the
economist, to decide on the allocation of resources. If you go back to Figure 5.5, you
would note that it shows interaction between various factors. It shows that inputs like
land, manpower, equipment and fertilizers and demand for food determine the food
supply /production. The data on food production is analyzed to develop policy by the
government. Food production also determines the prices of food in the market, which
affects the food availability and accessibility by consumers.
Let us now understand some issues related to food production. These are:
l factors influencing food production,
l analysis of food production,
l understanding the response of farmers, and
l developing a strategy.
108 Let us consider the first issue - factors influencing food production.
A. Factors influencing food production Health Economics
and Economics of
Appropriate food production involves getting an adequate output (i.e food) using Malnutrition
appropriate inputs. An essential requisite for this includes labour work-force and
good management skills to efficiently use the inputs. If we have skilled labour force
and if we can manage the inputs efficiently, the food production will increase. In
addition to these two factors, production also depends on: a) environmental, and
b) technical factors. Let us study these factors in detail:
a) Environmental factors:
You probably know that no agricultural region has a constant climate throughout
the year. This is true even in the tropical areas. The variations in climate influence
the cultivation patterns. For example, cultivation of rice necessitates adequate supply
of water and the dry season is hence unfavourable for rice cultivation. In addition,
there may be shortage of labourers in certain seasons. Elimination of these seasonal
bottlenecks will improve the food production. On the other hand, too much mechanization
will displace hired labour and prevent social gains. One also has to understand that
agricultural data also is subject to seasonal variation. So policy makers have to
analyze the data and formulate policy, having in mind the seasonal variation in
agricultural working pattern.
Seasonality brings in an element of risk and uncertainty for the farmer. This causes
the farmer to invest in crops, which are less influenced by changes in climate.
It also discourages him to invest more on technical inputs. The distribution of arable
land has important economic consequences. Issues related to food/fertilizer transportation
and food storage influence the availability and accessibility of food to the consumer.
Let us examine the technical factors in detail.
b) Technical factors
Improvement in technology has a significant impact on productivity. Improvements
may occur in seed production, fertilizer production, food processing, transportation
etc. Agricultural research is an expensive investment. So only few farmers have
the resources to carry out research. Advances in biotechnology have been more
popular in land-scarce societies and advance in mechanization have dominated the
land-rich societies.
In our discussion above, we have seen how environmental and technical factors
contribute to food production. We can collect various data on food production and
do the analysis of the data. It can be related to capital, labour or prices. The analysis
of data can help us predict information related to supply and prices etc. Let us
now consider the second issue of food production analysis of food production.
B. Analysis of food production

The agricultural sector is known for its diversity and heterogeneity of decisions right
from the farm to the entire marketing system. As mentioned earlier, an element
of uncertainty prevails for the farmers. It is important for analysts to know how
the farm-level decisions are made so as to bring appropriate changes in policies.
Analysts are ready to address the basic production decisions farmers must make
to function effectively year in and year out: what crops to produce, what combination
of inputs to use to produce them, and what total output to produce.
The supply curve as illustrated in Figure 5.6 is a very convenient conceptual and
empirical tool which summarizes a great deal of complicated producer decision
making in a simple two-dimensional diagram. The supply curve is an essential tool
in economists understanding of price formation in market economies, The supply
curve is a graphical representation of the relation between two factors – the capital
and the labour.
109
Public Nutrition
Figure 5.6: The supply curve
The supply curve depicted in Figure 5.6 has the capital plotted along the X-axis and
the labour along the Y-axis. Various curves are obtained for different combinations of
capital and labour and the appropriate one chosen for a given setting. Figure 5.6
illustrates four alternative techniques: hand labour (point D), oxen (point G), a small
tractor (point B), and large mechanized equipment (point A). The isoquant connecting
these points portrays the possible technical alternatives for growing 100 kilograms of
rice. The appropriate combination of labour and capital is determined by the prices of
the inputs.
Thus, we see that using a simple empirical tool like a supply curve, food production
at various combination of labour and capital can be predicted which can help economists
in understanding of price formation in market economies. Location of the supply curve
is affected by the government policies, which in turn affects the food production.
Although government policy may be favourable to the farmers, it is important to
understand how the farmers will react to a particular situation. We will now look at
the third issue related to food production i.e. understanding farmers’ response.
C. Understanding the response of farmers
Understanding the response of the farmers by the government also influences the food
production. Government policy influences the location of the supply curve directly
through investments that lower marginal costs of agricultural production and indirectly
by influencing the decision of the farmer, as price policies alter the incentives to use
more intensive techniques of farming to produce more output. Though, government
can bring changes in the policy, it is important to know how the farmers may react
to the situation. This issue can be addressed only by careful attention to exactly which
question is being asked, coupled with specific statistical analysis of country or regional
data.
Describing the agricultural sector in statistical terms is complicated by agriculture’s
unique characteristics. Annual production statistics by crop for the entire country can
be obtained but this doesn’t reflect the decisions taken by the individual farmers.
Moreover each farm setting is unique in its own sense. A model, which may be
successful in one area, may not work in another area. This necessitates to collect data
(e.g. village-level surveys etc.) from a variety of ecological settings (i.e. different
types of agricultural lands). To serve this purpose, the arable land is divided into
Agroclimatic zones, where similar ecological zones are grouped together. Data is
collected from selected areas of each zone. The data may cover the following issues:
l how farming systems are likely to respond to policy changes,
l type of crops grown,
l farm-size distribution,
l farm prices, yields, profitability data,
110
l the ratio of commodity prices received by farmers to the price paid for a key input Health Economics
such as fertilizer provides a rough assessment of how tightly the agricultural and Economics of
Malnutrition
sector is being squeezed by low economic incentives relative to other regions and
countries.
l comparing regional prices with international prices.
Thus, we see that food production will vary depending upon how farmers response to
policy of the government. India being such a diverse country, each farm-setting is
unique. Therefore, survey is required for different settings and data, is analyzed to
understand many issues related to production and prices.
We have seen earlier that it is essential to understand the factors influencing food
production analyze food production data and understand farmers’ response. Last and
the fourth issue of food production, then becomes, that an appropriate strategy is
developed which would help in bringing an improvement in rural economy. Let us see
how and why we do that briefly.
D. Developing a strategy
It is necessary to develop a strategy that results in improvement in the rural economy.

This could be achieved by framing policies which can pump more money into the rural
sector. This would also result in improvement of employment opportunities in the rural
areas. It can thus be concluded that, for successful food production, it is necessary to
understand the decision making process of the farmers and the policy formulated
accordingly.
So, we studied about the four issues related to food production. These are factors
influencing food production, analyses of food production, understanding the response of
farmers and developing a strategy. A thorough understanding of these issues is important
before making a policy change and planning an intervention to improve food production
in the country.
We will now study the second major aspect of nutrition economics i.e. Food pricing.
5.4.3 Food Pricing

The pricing of the food products bought by the consumer is subject to multifarious
factors. Each of the factors as discussed below can affect the pricing both in the
interest of the consumer and against it. An overview of these factors will help one
understand the umpteen tasks faced by the policy makers in achieving at a decision
which will be in the best interest of the consumer, as well as, will help positively
towards the burden of the malnutrition in the community.
The costs of storage, transportation, processing- which are known as the marketing
transformations  are an integral component of food price formation. The storage at
the non-harvest season can increase the prices due to logistic reasons or due to the
wish of the storage-marketer to look for some gains during the non-harvest season.
The transportation costs may rise with the increase of the distance between the
production point, and the final consumer. Also, poor conditions of the roads and
communication will contribute into the increase of the price. Processing, e.g. the milling
of the rice before selling it to the consumer will increase the price, but then consumer
also prefer it more as compared to the raw unmilled rice directly from the farm.
Seasonality by virtue of the harvest and the non-harvest seasons will affect the pricing.
Pricing will increase with the demand, e.g. local food habits will determine the pricing
of a grain in respect to its acceptability in the local population.
111
Public Nutrition Increasing the prices of the seeds, fertilizers, pesticides, and other farm related
equipments will increase the prices of the grain, but at the same time these things if
are under subsidy from the government, can help in decreasing the prices.
Markets do not always function in the best interests of a broad cross section of
society. Highly unequal financial bargaining power is often brought to the exchange
relationship between seller and buyer. In the absence of any price regulatory body, all
the middlemen involved right from the level of the production to the level of the
consumption may have a wishful interest in the pricing. Thus, more is the number of
the middlemen in the path, more the prices will increase.
A shortage of food means high prices in a market economy, with only the well-to-do
able to purchase it. A food shortage in a socialist economy means rationing, with
perhaps little choice about what the poor can eat. Competition and the number of
market participants affect the logic of decision-making behaviour. For competition to
be effective, however, there must be an adequate number of participants on both sides
of the exchange relationship so that no single agent can significantly influence the
outcome of the exchange. Farmer’s range of choice at the initial point of sale is the
first step in understanding how competitive price formation is likely to be. The more
agents there are competing to buy the farmer’s grain, the better the information
available to the farmer about the prevailing price and the easier it is to switch from
one buyer to another whose terms are relatively better. At the opposite end of the
marketing chain, where consumers buy foods if many alternative retail stalls offer
similar commodities and services, the freedom of consumers to choose one retailer
over another prevents excess profits from high margins accruing to the retail-marketing
agents.
Government induced subsidy directly to a commodity will help in decreasing the

prices. International markets affect the prices in an intricate way. Actually the domestic
markets are in an effect only a networking between the various international markets,
so it is not astonishing to find the price getting affected as a result of the international
price correlation.
The cost of the labour involved at every stage will increase the prices. Tax levied by
the government will also increase the prices. Thus, we see that there are many
factors, which influence the price of the food commodities. Food commodities available
at affordable prices by the poor can go a long way to improve the food security of
vulnerable population and thus help improving their dietary intakes.
In the above section, we studied about economics of health and nutrition. We looked
at various health and food resources required to improve nutritional status of population.
We also analyzed various economic consequences of malnutrition. Now we will review
how we can efficiently plan and allocate these limited resources to alleviate the large
problem of malnutrition. Thus, in the next section, we will explore the concept of
economic evaluation of malnutrition. But before moving on to this topic let us check
our understanding on the subject so far by answering the questions given in check
your progress exercise 2.
1. What is Food Security? Enumerte the three causes for food insecurity.
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112
Health Economics
2. Define the term nutrition security and list any four initiatives to improve nutritional and Economics of
status. Malnutrition
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3. Explain in brief the factors responsible for food pricing.
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4. What are the various issues related to food production and explain any one in
brief?
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5.5 ECONOMIC EVALUATION OF MALNUTRITION

You must be familiar with a proverb frequently used in the field of economics, which
says--- “resources are limited and wants are unlimited”. This can be applied to the area
of programme planning also for alleviating malnutrition. Shortage of resources is
constantly faced by programme planners where they try to make the best use of the
limited resources using it for the programmes which will yield the best results. Taking
into consideration the scarcity of resources, especially in developing countries, it becomes
important for the decision makers to strike the most favourable balance between the
health benefits achieved and the cost incurred. At some point, the society must decide
one programme in preference to an alternative. The term ‘opportunity cost’ describes
the link between the scarcity of resources and sacrifices made by the society.
So, how do we know which intervention is better than the other in terms of the
health benefits or which is least expensive strategy for achieving the same
health outcome? We can find that out by conducting an economic evaluation. Economic
evaluation in the health care sector consists of comparing two or more health care
interventions in terms of their cost and consequences as described earlier in Table 5.1.
There are two objectives of economic evaluation. These are:
1. To introduce resource consideration into analysis and to assess the opportunity
cost of new procedures and programmes (preventive, diagnostic, therapeutic,
rehabilitative)
2. To develop a framework within which the costs of the new procedures or
programmes can be compared to their benefits.
Depending upon what objective we want to achieve, we can conduct three types of
economic evaluation:
l cost-effectiveness analysis,
l cost-utility analysis, and
l cost-benefit analysis.
113
Public Nutrition Let us discuss these briefly:
l Cost effective analysis: Cost effective analysis provides for the choice of least
expensive strategy at the least cost. Here the outcome is measured in terms of
natural units e.g. life-years gained, number of children prevented from developing
malnutrition etc.
l Cost utility analysis: Cost utility analysis provides for measurement of health
outcomes for a given cost. The health outcomes are measured quantitatively, as
well as, qualitatively. These can be quality-adjusted life years (QALY) or health
years equivalent (HYEs).
l Cost-benefit analysis: Cost benefit analysis is a useful tool to establish the
priority of a particular health service action. In this, both inputs and outputs are
measured in monetary terms. Cost benefit analysis is probably most useful for
health programmes that have a major impact on economic development.
You would note here that the first step for economic evaluation is to estimate the cost
of intervention that is being used for control or prevention. The process of identification,
measurement and valuation of costs associated with each alternative are identical in
all three methods. The difference lies in the way the consequences are measured and
valued as represented in Figure 5.7. Which depicts the components of economic
evaluation.
Resources consumed Health Care Health Improvements
(Inputs) Technology (Outputs)
Cost (C) Effects (E) Utilities (U) Benefits (B)

C1 = Direct costs Health effects Health effects Associated economic
C2 = Indirect costs in natural units in quality adjusted benefits
C3 = Intangible costs life-years B1 = Direct benefits
B2 = Indirect benefits
B3 = Intangible benefits
Figure 5.7: Components of economic evaluation

Figure 5.7 shows cost incurred in terms of resources consumed (inputs). These
resources with the use of health care technology yield improvements in health, which
can be measured in terms of benefits, utilities and effects.
So, we can conduct any type of economic evaluation depending upon what our objectives
are for use of resources and measurement of benefits. Policy makers to make
decisions regarding allocation of limited resources generally use economic evaluation.
But have you ever wondered what does it cost to a nation on a yearly basis when we
have several people suffering from malnutrition? We use the term “annual productivity
loss” to calculate this loss to the nation. Let us find out more about it in the next
section.
Annual productivity loss
The above section dealt with optimum use of resources and the kind of health benefits
obtained with the use of those resources to prevent and control malnutrition. When
people suffer from malnutrition or any specific micronutrient deficiency, their productivity
at work decreases. For example, when they have iron deficiency anaemia, their work
capacity may reduce and they may be more susceptible to infection. With the result,
they are more likely to produce at less than optimal level or miss out from work due
to sickness. Missing out time from work is known as productivity loss. Nowadays,
there is a constant pressure on health care research personnel to calculate productivity
loss due to health consequences. Productivity loss can be measured using 3 parameters
which include productive life expectancy, average annual wage for an adult and
114
average rate of employment.
Thus, the formula given for calculation of annual productivity loss is: Health Economics
and Economics of
Annual productivity loss = (n*p*w*e) + (d*pe*w*e) Malnutrition
where,
n = no. of adults suffering from deficiency disorder
p = productivity loss due to disorder
w = annual wage
e = employment rates
d = death due to disorder
pe = productive life expectancy
The assumed productivity loss (p) due to different deficiency disorder is given in Table
5.6 and can be used in the formula above.
Table 5.6: Productivity loss due to different deficiency disorders
Nutrient Deficiency Assumed Productivity
Disorder Loss (%)
Calories CED 10%
Obesity (CEE) ?
Iron Anaemia 20%
Iodine Mild iodine deficiency 5%
Cretinism 50%
Vitamin A Partial blindness 25%
Total blindness 50%
Source: *Assumptions made by Judith McGuire et al., National strategy to reduce childhood
malnutrition: Final Report; Min of HR&D:GOI, Administrative staff college of India,
Hyderabad. Dec, 1997.
Let us understand the concept of productivity loss with the help of an example. We
can take the case of anaemia and calculate the annual productivity loss as follows:
Let us assume
Productive life expectancy (years) = 15.6
Annual wage for an adult = Rs.3500
Average rate of employment = 75%
No. of adults suffering from anaemia = 5000000 (hypothetical figure)
No. of deaths attribute to anaemia = 10,000
Annual productivity loss for anaemia of a given geographic area for the given year
= ( 5000000*.20*3500*.75) + (10,000*15.6*3500*.75)
= 2625000000 + 409500000
= 3034500000
= Rs. 3 billion/yr
In the table above productivity loss due to obesity is not included. Some evidence
suggests that obesity, in particular, is associated with an increased risk of temporary
work loss such as sick leave (absenteeism) and reduced productivity while being
present at work (presenteeism). It is also associated with permanent work loss, which
includes disability pension and premature death. Recent reviews have found strong
evidence that temporary and permanent work loss attributable to obesity result in a
substantial burden for national health and insurance pension systems. 115
Public Nutrition The example of calculating annual productivity loss presented above is based on
hypothetical figures.
You would be surprised to know that the total estimated annual productivity losses
(2010) for India for micronutrient deficiency is approximately Rs. 3914 billion (low
scenario) to 1000 billion (high scenario). Isn’t that too much? If we eliminate
malnutrition, then productivity of people of our country will increase and we would
have a monetary gain of Rs. 1000.0 billion in terms of increased goods and services
and better quality of life for people.
With this we end our study on the economics of malnutrition. We hope having gone
through the concepts present in this unit you would realize what is the cost of malnutrition
and how economic evaluation of malnutrition keeps to plan the targeting of resources
for alleviating the problem.
Check Your Progress Excercise 3

1. Fill in the Blanks:
a. ....................................... benefit analysis is a useful tool to establish the
priority of a particular health service action.
b. Missing out time from work is known as ....................................... loss.
c. .......................................and ....................................... are health
outcomes measured quantitatively as well as qualitatively as part of the
cost utility analysis.
d. ....................................... is the term which describes the link between
scarcity of resources and sacrifices made by the society.
c. The full form of QALY is.......................................
2. Give the formula for Annual Productivity Loss with complete expansion.
........................................................................................................................
........................................................................................................................
........................................................................................................................
5.6 LET US SUM UP

This unit focused on the economics of malnutrition. The major points emerging from
this unit were:
l Health economics concentrates on application of the principles and rules of
economics in the sphere of health. In broad terms, it includes analysis and
evaluation of health policy and the health system from an economic perspective.
l Malnutrition causes huge amount of economic losses to the nation. The causes
of malnutrition are multifactorial and interventions have to be done at various
levels.
l Nutrition economics deals with many issues relating to food resources such as
food pricing, food production, food marketing and food storage etc. The discipline
tries to analyze relationship between all these issues so that food resources can
be adequately planned, equitably distributed and efficiently used to improve the
nutritional situation of the people.
l Food security is access by all people at all times for enough food to lead an
active health life. Food security can be at the individual level, household level and
at the community level. In a given situation food insecurity can result from the
following three causes: These are related to availability, accessibility and appropriate
116 utilization of the food.
l Economic evaluations play an important role to estimate the burden of a given Health Economics
public health problem and help in planning and policy making. and Economics of
Malnutrition
5.7 GLOSSARY
Biotechnology : biotechnology describes the use of organisms and biological
processes to provide food, chemicals and services to meet the
needs of humans.
Isoquant : locus of all input combinations that yield the same level of output.
Pathological : the branch of medical science that studies the causes, nature and
effects of diseases.
Synergistic : action of two or more substances to produce an effect that neither
alone could accomplish.

EXCERCISES
1. Health economics is concerned with analysis and evaluation of health policy and
the health system from an economic perspective. In particular, it includes health
system planning, market mechanisms, demand for and supply of health care,
economic evaluation of individual diagnostic and therapeutic procedures,
determinants of health and its evaluation, and evaluation of the performance of
health care systems in terms of equity and allocative efficiency.
2. When an individual is malnourished his/her economic productivity falls. This further
deteriorates the nutritional status of the individual. Economic productivity of the
individual influences the household real income which influences the household
food availability and food allocation in the family. When household real income
falls as a result of low economic productivity, families have less food available for
different members of the families. Poor food consumption contributes to low
nutritional status of the family members especially the mother and the child.
Mothers with poor nutritional status have low capacity to take care of the child.
This insult to the child has long term consequences in terms of growth, cognitive
capabilities, morbidities and mortalities etc. This results in loss of productivity in
school. For adults, poor nutritional status leads to reduced stamina and endurance
and low physical capacity at work, thus contributing to reduced economic
productivity. So this loss of productivity influences economic status of the family,
which can further deteriorate or prevent improvement of the nutritional status.
3. Total Government spending on nutrition covers what the GOI and state government
spend on nutrition programmes. Under direct nutrition programmes, spending on
ICDS is the highest (67%) followed by NMMP (30%) and Micronutrient and
other programmes (3%).Under the indirect nutrition programmes, spending on
PDS was 99% followed by employment assurance schemes (1%).
1. Food security is access by all people at all times to enough food for an active
healthy life. The three major causes for food insecurity are:
 Food availability
 Food access
 Food utilization/consumption
117
Public Nutrition 2. Nutrition security is defined as a balance between biological requirements in
energy and nutrients and the quantity and quality of food consumed. The four
initiatives to improve nutritional status are increasing food production – building
buffer stock, building up the PDS, nutrition education, food supplementation.
3. The various factors that affect food pricing are storage, transportation, and
processing.
4. The major issues related to food production are factors influencing food production,
analysis of food production, understanding the response of farmers, and developing
a strategy.
1. a. Cost
b. Productivity
c. QALY, HYES
d. Opportunity Cost
e. Quality Adjusted Life Years
2. The formula for Annual Productivity Loss is:
Annual Productivity Loss = (N* p* w* e) + (d* pe* w* e*)
Where, N = no. of adults suffering form deficiency disorder
P = productivity loss due to disorder
W = annual wage
E = employment rates
D = death due to disorder
pe = productive life expectancy
118
UNIT 6 POPULATION DYNAMICS Population Dynamics
Structure
6.1 Introduction
6.2 Demography, Demographic Transition and Demographic Cycle
6.3 Population Trends in India
6.4 Population Structure
6.4.1 Sex Composition of the Population
6.4.2 Age Composition
6.4.3 Fertility Behaviour
6.5 Vital Statistics and Implications of Vital Statistics in Population Growth

6.6 Population Policy
6.7 Relationship between Fertility, Nutrition and Quality of Life
6.8 Let Us Sum Up
6.9 Glossary
6.1 INTRODUCTION
In Unit 1, we learnt that public nutrition is concerned with improving nutrition situation
of population. Units 3 and 4 focused on various nutrition problems existing in India
and other developing countries. Unit 5 highlighted the economic cost of malnutrition.
In this unit, we are going to study about human population who eventually suffer from
these problems.
Why do we want to study about human population? We want to study about this
because we want to know what changes are taking place in human population. For
example, what are trends in population growth? What changes are taking place in
structure and composition of human population? As a public nutritionist, we want to
know about these aspects because this would help us estimate various needs of
population such as food and health care needs, plan programme strategies and work
towards solving the nutrition problems. In this unit, we are going to study about all
these aspects.
Objectives
l explain the concept of demography, demographic transition and demographic

cycle;
l highlight the population trends and structure in India;
l describe the implications of important vital statistics on population growth and

trends;
l list the factors affecting population growth;
l discuss the concept of population control in India; and
l explain the implications of population growth on quality of life.

119
Public Nutrition
6.2 DEMOGRAPHY, DEMOGRAPHIC TRANSITION
AND DEMOGRAPHIC CYCLE
We know that population of different countries in the world is always changing. For
some countries like India and China, the population is increasing at a very fast rate,
while for others e.g. U.S., it is increasing at a slower rate, in some countries it is even
declining e.g. in Sweden and Hungary. All the countries of the world pass through
different stages in population growth and accordingly exhibit changes in population
growth. In this section, we will learn about the different stages of population growth
and how they affect the changes in population scenario. We will familiarize you with
certain concepts which are frequently used in the study of population. These concepts
are --- demography, demographic transition and demographic cycle. Let us start with
demography.
What is demography?
The scientific study of human population is termed as ‘Demography’. It focuses
attention on three readily observable human phenomena:
a. Changes in population size (growth or decline),
b. The composition of the population, and
c. The distribution of population in space.
There are five major demographic processes, which are continually at work within
the population namely, fertility, mortality, marriage, migration and social mobility. You
would realize that these processes determine the size, composition, distribution and
development of the population.
The health of the population depends upon the dynamic relationship between the
number of people, the space, which they occupy, and the skill that they have acquired
in providing for their needs. There are continuous changes occurring in the structure,
and composition of the population of most of the countries of the world. So then,
where do we get all the information related to population? In India, we get our
demographic statistics mainly from population censuses, National Sample Surveys,
registration of vital events and demographic studies. July 11 is celebrated as the
World Population Day. On July 11, 1999, the population of the world reached the
mark of six billion people.
This brings up to the next issue of demographic transition. Let us get to know about
demographic transition:
What is Demographic Transition?

The whole process of change with regard to population size and characteristics is
called demographic transition. In order to understand this term better, let us learn
about demographic cycle.
What is a Demographic Cycle?

It is a cycle which evolves as population grows in size. The history of world population
suggests that there is a demographic cycle of five stages through which a nation
passes. These stages of demographic cycle are enumerated herewith.
a) First Stage
High Stationary - This stage is characterized by high birth rate and a high death
rate neutralizing each other and hence the population remains stationary. India
was in this stage till 1920.
120
b) Second Stage Population Dynamics
Early Expanding - The death rate begins to decline but birth rate remains high,
thereby resulting in increase in population.
c) Third Stage
Late Expanding - The death rate declines further and birth rate begins to fall.
The population continues to grow because births exceed deaths. India appears
to be in this stage at the moment where there is high growth with definite signs
of slowing down.
d) Fourth Stage
Low Stationary - This stage is characterized by low death rate and low birth rate,
as a result of which the population becomes stationary. This is also called the
zero population growth. Most of the developed nations have undergone
demographic transition shifting from high birth and high death rates to low birth
and low death rates and are currently in this phase.
e) Fifth Stage
Declining - There are more deaths than births resulting in decline in population.
This is also called the negative growth phase. Some countries like Sweden and
Hungary have entered this stage. Socially, this stage of demographic transition
is not desirable as it results in total changes in age structure, leading to progressive
aging of the population.
Thus, we have learnt so far that different countries are at different stages of demographic
cycle and accordingly exhibit changes in the population growth. India is at the third
stage where the population is still growing although the rate of growth seems to be
slowing down. You may probably be aware that in India we face a lot of problems due
to excessive growth in population. So what are the negative effects of excessive
growth in population? Let us review these.
Continuous and excessive growth of population is interpreted as major ill of contemporary
national societies, both developing and industrialized. In the former case, rapid population
growth is seen as a major barrier to the processes of development. In the latter, people
are seen as polluters, herding into vast and expanding cities like Mumbai or Delhi and
destroying natural environments.
Unlike the developed nations where they have witnessed demographic transition, the
situation of most of the developing societies, have few favourable attributes. Many
countries, particularly in Asia have a high man-land ratio i.e. population density. The
density of population in India as per 1991 census was 273 and as per 2001 census is
324. With 2.4% of the world land area, India is presently supporting 16% of the world
population. Currently about 80% of the world’s population is living in the developing
countries. Out of the 90 million people added every year, all but six million will live in
developing countries. One third of the population lives in China and India. India has the
second largest population in the world. The total population of the country was 846.3
million on first March 1991 and as per 2011 census it has crossed 1 billion mark and
is 1.21 billion and now as per 2018 estimates population of India has reached to 1.35
billion.
Thus, it is interesting to note that in the developing nations, as a result of applications
of public health measures and improved medical care mortality rates have taken a
steep downward trend, whereas, the birth rates have not declined correspondingly, thus
causing mushrooming in population growth. The rampant population growth has been
viewed as the greatest single obstacle to the economic and social advancement of the
majority of people in the underdeveloped world, which is true for India.
We will now study how and in what way the population is growing in India. i. e. what
are the population trends in India. 121
Public Nutrition
6.3 POPULATION TRENDS IN INDIA
In the population trends, we will study about the pattern of population growth in India.
We will examine the population trends in terms of :
l How the overall growth in population has occurred in India?,
l How the urbanization is affecting the population growth pattern in urban versus
rural areas?, and
l What are the interstate variations in population growth rate?.
Let us review these trends one by one.
How the overall growth in population has occurred in India?
The growth of population in our country is a recent phenomenon. The population had
been fluctuating and growing very slowly until about 1921. The year 1921 is called the
‘big divide’ because the absolute number of people added to the population during each
decade has been on the increase since 1921. The growth of population is a result of
declining general mortality, infant morality and increase in expectation of life at birth.
The period from 1921-51 was one of slow but steady growth. During the next five
decades, mortality declined by nearly 57% from 22.8/1000 in 1951-61 to 7.3/1000 in
2011. The birth rate also declined during these years but at a much slower pace
reaching a level of 22.5/1000 in 2011 from 41.7 in 1951-61. The decadal growth of
population of India from 1901 to 2011 is shown in Table 6.1 and Figure 6.1.
Table 6.1: Population of India, 1901-2011
Census Year Total Population Average Annual Exponential

(in million) Growth Rate (Percent)
1901 238.4 -
1911 252.1 0.56
1921 251.3 - 0.03
1931 279.0 1.04
1941 318.7 1.33
1951 361.1 1.25
1961 439.2 1.96
1971 548.2 2.20
1981 683.3 2.22
1991 846.3 2.14
2001 1027.0 1.93
2011 1210 1.64
2025 * 1388.9*
* Projections
Source : Report of the Technical group on population projections May 2006, National
Commission on Population Registrar General of India.
As you can note from Table 6.1, India’s population has grown approximately four times
in the last century viz. from 1901 to 2011. We were 238.4 million in 1901 and as per
2011 census we have increased to 1210 million people. Further, the absolute addition
to the population in the decade 2001-2011 was about 181.46 million which is almost
122
Population Dynamics
Figure 6.1: India - Decadal growth of population 1901-2011
equal to the population added during the three decades 1931-61. The average exponential
growth rate of population has registered the sharpest decline from 2.72% during
1971-81 to 1.64% during 2001-2011 Figure 6.1 shows that decadal growth has been
rising steadily since 1921. As per census 2011, the total population of India is 1210.8
million with a decadal growth rate of 17.7%.
You must have heard or read about “ urbanization” in T.V or newspaper. Let us find
what do we exactly mean by urbanization and how this affects population trends.
How the urbanization is affecting the population growth pattern in urban versus
rural areas?
Urbanization is the process whereby larger and larger proportions of population
live in urban areas. Urbanization can result by two ways. First, by accretion of
population to already existing towns and second, by the transformation of a rural area
into an urban area.
As per 2011 census, out of the total population, 377 million people were residing in
urban areas and 833 million in rural areas. There has been a sharp increase in the
urban population, during 2001-2011, which has increased about 3.35% proportion of
urban population in the country.
Growing urbanization is a recent and unstoppable phenomenon, in developing countries.
With the advances in industrialization, more and more people are being attracted
towards the industrial centres. The migration of people from countryside to urban
areas constitutes a social crisis, which ultimately affects the quality of life of people.
Our country faces the emerging problem of growing urban slum population. Rural
folks migrate to cities in search of employment and better social status. These migrants
settle in cities in places where sub-optimal infrastructure for housing, electricity and
sewerage system is available. Generally, slum populations have more young people
123
Public Nutrition and children and fewer elderly than the population as a whole. Slums on the whole
have lower sex ratios than the cities in which they are located. Slum dwellers are very
poor rural migrants, primarily from lower caste or disadvantaged communities, who are
pushed to the cities through caste, kinship and village networks. You would realize that
it is this group of people who are the most disadvantaged from nutrition, health point
of view. Thus, from our discussion so far, it must be clear, how population is rising at
a faster rate in cities compared with rural areas. Different states in India have different
growth rates of population and that affects population trends in India. Let us next
review the interstate variations in population growth in our country.
What are the interstate variations in population growth rate?
There is a wide variation in the growth rate of different states, during 1991-2001 among
the major states, four states Bihar, J & K, Jharkhand and Chhattigarh recorded annual
growth higher than 2.0%.
Figure 6.2 shows decadal growth of population in different states over the inter-
censual period 2001-2011. You would note from Figure 6.2 that the highest decadal
growth rate of population was recorded in Dadra & Nagar Haveli (56%) and lowest
in Nagaland.
PERCENTAGE INCREASE
Figure 6.2 : Decadal growth of population 1991-2011
Therefore, over the period of ten years from 1991-2011, some states have shown
higher population growth rates than others.
In this section, we studied about how and in what way population has grown in India
as a whole and the pattern of its growth within India. i.e in urban, rural, as well as,
124
in different states. In the next section, we will study about the structure of population Population Dynamics
in terms of age, sex and fertility behaviour. But before that, let us check what we have
learnt so far.

1. What do you understand by the term ‘Demography’? What are the aspects it
focuses on?
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
2. List the stages of the demographic cycle through which a nation passes?
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
3. Why is the year 1921 called the ‘big divide’?
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
We will now study about population structure. Under this, we will study about structure
of population in terms of age and sex composition. We will also study about fertility
behaviour because fertility behaviour affects the age and sex composition of the
population. For example, in our society there is a preference for a male child. At times,
after the birth of a daughter, couples continue to have children until they have a son.
All these factors will have an effect on age and sex composition of the population and
also the health/nutrition status.
6.4 POPULATION STRUCTURE

The structure of population can be viewed as to how the population is composed of
in terms of age and sex. The structure of population can also vary depending upon when
and how many children women have i.e. their fertility behaviour. So, we can study the
population structure in terms of sex composition, age composition and fertility behaviour.
Let us begin with sex composition of the population.
6.4.1 Sex Composition of the Population
Sex composition of human population is one of the basic demographic characteristics,
which is extremely vital for any meaningful demographic analysis. The sex composition
of the population is affected by sex ratio at birth, differentials in mortality conditions of
males and females and sex selective migration. You must have read in the newspaper
or heard over T.V., radio that the sex ratio is declining in India. So, what do we mean
by sex ratio? Let Us find out.
What is Sex Ratio?
Sex Ratio is defined as “the number of females per 1000 males”. Sex ratio is an
important social indicator to measure the extent of prevailing equity between males and
females in a society at a given point of time. The sex ratio in India has been generally
adverse to women, the sex ratio has also declined over the decades. Sex ratio is a
crucial indicator of women’s health status and survival. In India, ever since 1901,
almost every census has recorded a decline in the sex ratio, except for a slight abatement
of the trend during 1940’s consequent to the world war and a small improvement from
1971 to 2011. Table 6.2 depicts the sex ratio in the country from 1901 onwards. 125
Public Nutrition Table 6.2: Sex ratio in India 1901-2011
Year Females/1000 Males
1901 972
1911 964
1921 955
1931 950
1941 945
1951 946
1961 941
1971 930
1981 934
1991 927
2001 933
2011 943
There is a considerable variation in the sex ratios between the States and Union
Territories. In 2011, Kerala had the highest sex ratio of 1084 followed by Puducherry
(1038). The lowest sex ration of 618 was observed in the Union Territory of Daman
& Diu. Along with some Asian neighbours like China, Bangladesh, Sri Lanka and
Nepal, the sex ratio in India is lowest in the world. You must be curious to know why
the sex ratio is falling in India.
Let us now review this.
Why is sex ratio falling in India?
The females initiate their lives right from birth at a disadvantage. When one looks at
the sex ratio in Indian children, it decreases from 977.60 in 0-4 years age group to
940.97 at 5-9 years and then 897.95 at 10-14 years of age. To understand this
demographic distortion, various explanations are available like the sex selective feeding
and child rearing practices, sex selective female abortions, female infanticide and
female selective mortality. The age specific mortality over 1972-2001 shows that
though the rate has been falling for the population on the whole, the female deaths
remain consistently higher. Also, when one looks at the age specific sex ratios, there
are two depressions where the sex ratio drops well below the average for the following
periods  first in the late childhood and adolescence and second during 30 to 40 years
of age and 50-60 years of age, reflecting their perils of the reproductive periods and
long periods of heavy work under adverse circumstances.
We discussed above that due to discriminatory practices against women, sex ratio is
falling in India and that is influencing the sex composition of the Indian population. We
are gradually moving towards having more men and less women as a part of our
population. Let us now study about age composition as it influences the structure of
the population.
6.4.2 Age Composition

The age structure of a population is best represented as shown in Figure 6.3. This type
of representation is called an ‘Age Pyramid’. Figure 6.3 gives the age structure of
Indian population in 1990 and 2025 (as projected).
126
Population Dynamics
Figure 6.3: Age structure of population (Male and Female), 1990-2025 (percentages)
The age pyramid of India in 1990 as shown in the Figure 6.3 is typical of under-
developed countries, with a broad base and a tapering top. In the developed countries,
the pyramid generally shows a bulge in the middle and has a narrower base, reflecting
a higher proportion of productive working population and a lower proportion of
dependents. So, who comprises dependents as per census? The child population (0-
14 years) and elderly population (65 years and above) comprise dependents. The age
group 0-14 years for children is further split into 0-4, 5-9 and 10-14 years, keeping in
mind their different health and social needs.
There is another term which we need to know about, that is dependency ratio. The
ratio of the combined age groups 0-14 years plus 65 years and above to the 15-65
years age group is termed dependency ratio. In India, the age structure of the
population is changing so the dependency ratio is likely to decrease. The proportion
of the population in the working age group of 15-59 years is likely to increase by 2025.
There is another transition known as “ageing transition” which is happening in our
country. A sharp decline in death rates and an increase in life expectancy in post
independence period is resulting in demographic transition, which can be called ‘ageing
transition’. In 1989, there were 37.1% and 4.3% people in the age category 0-14
years (children) and >64 years (elderly), respectively and 58.6 in the productive age
category of 15 to 64 years. But by 2025 there will be 24.1% and 7.5% in 0-14 years
and >64 years, respectively and about 68.4% in 15-64 years age group. Thus, the
numbers of aged will approximately double registering more than four-fold increase in
absolute numbers. Considering that the elderly are subjected to highest incidence of
sickness along with young children and also higher levels of morbidity, it may pose as
an economic burden for the country. This ultimately will result in reordering of the
priorities with respect to health care. The working adult population will have to sustain
and support the increasing elderly population.
In our discussion above we have described how the population structure in India is
changing with respect to the age of the people. In the years to come, we will have
more elderly people comprising the population compared to what we have now.
Next, let us study about fertility behaviour, since this also affects structure of population.
6.4.3 Fertility Behaviour
Actual bearing of children is termed as ‘fertility’. A woman’s reproductive period is
roughly from 15 to 45 years  a period of 30 years. Information on fertility in India
indicates that an average woman gives birth to an average of six or seven children,
if her married life is uninterrupted. This has great implications on the nutrition and
health status of women in our country.
The high fertility in India is attributed to universality of marriage, lower age at marriage,
low level of literacy, poor level of living, limited use of contraceptives and traditional
ways of life. Some of the factors which affect fertility are: 127
Public Nutrition 1. Age at marriage - The age at which a female marries and enters the reproductive
period of life has a great impact on her fertility. National data from Registrar
General of India suggests that females who marry before the age of 18 gave
birth to a large number of children than those who married later in life.
Demographers have estimated that if marriages were postponed from the age of
16 years to 20-21 years of age, the number of births would decrease by 20-30
percent. Although, the mean age at marriage for girls has moved to 18 years in
many states, but in rural areas of Madhya Pradesh, Rajasthan and Uttar Pradesh
a substantial proportion of marriages continue to take place when the girl is
around 15 years of age. This makes the girl child in India ‘at risk’ to disease and
malnutrition.
2. Duration of married life - Demographic studies indicate 10-25 percent of all births
occur within 1-5 years of married life; 5-55 percent of all births within 5-15 years
of married life. Births after 25 years of married life are very few. Therefore,
family planning efforts should be concentrated in the first few yeas of married life
in order to achieve tangible results.
3. Spacing of children - Studies have shown that when all births are postponed by
one year, in each age group, there was a decline in total fertility. Spacing of
children may have a significant impact on the general reduction in fertility rates.
The other big advantage is that we can also reduce the infant and child mortality.
New observations from Demographic and Health Surveys (DHS) programme
(2002) show that children born 3 to 5 years after a previous birth are healthier
at birth and more likely to survive at all stages of infancy and childhood through
age five than children born before 3 years of age.
4. Literacy - Women’s literacy is one of the critical factors that determines and
enables them to achieve their reproductive goals. Literacy improves awareness
and enables women to access services, this improve their own well being, survival
of their offspring and access to contraception. According to NFHS-4 (2015-16)
survey the total fertility rate are 1.75% among the urban women's. In the rural
areas the fertility rate estimated are quite high with a figure of 2.4%.
5. Economic status - Operational research studies support the hypothesis that
economic status bears an inverse relationship with fertility. The total number of
children born declines with an increase in per capita expenditure of the household.
People in the high economic group view having children as an investment, whereas
for poor people children are an asset and source of extra income.
6. Caste and Religion - The NFHS-4 (2005-16) Survey, reported a total fertility
rate of 2.62 among Muslims as compared to 2.13 among Hindus. Whereas, the
total fertility rate amongst Christians was found to be 1.99. Among Hindus, the
lower castes appear to have a higher fertility than the higher castes.
7. Nutrition - There appears to be some relationship between nutritional status and
fertility levels. Virtually, all well-fed societies have low fertility and poorly fed
societies high fertility.
8. Family planning - It is an important factor in fertility reduction in a number of
developing countries, family planning has been a key factor in declining fertility.
Family planning programmes can be initiated rapidly and require only limited
resources, as compared to other interventions for reduction in fertility.
9. Cultural preference for son - In our Indian society, the cultural preference for
sons is strong and many couples have another child soon after the birth of a
daughter and continue having children until the birth of a son. This phenomena has
been termed by some demographers as “son syndrome”.
10. Other factors - Fertility is affected by a number of physical, biological, social and
cultural factors such as place of women in society, value of children in society,
widow remarriage, breast feeding, customs and beliefs, industrialization and
urbanization, better health conditions, housing opportunities for women and local
128
community involvement. Attention to these factors requires long-term government Population Dynamics
programmes and large amount of money.
So we have learnt how different factors affect a women’s fertility behaviour. Depending
upon how many children a woman has and at what time during her reproductive life,
it will affect the structure of the population over a period of time.
Reading through this unit, we came across certain terms like birth rate, death rate and
fertility rate etc. These terms are a part of the vital statistics. It is important for us
learn about vital statistics because they are frequently used in the study of population.
Let us now study about certain vital statistics in detail.
6.5 VITAL STATISTICS AND IMPLICATIONS OF

VITAL STATISTICS IN POPULATION GROWTH
Vital statistics are data concerning the important events in human life such as
births, deaths, marriages, migrations, etc within a population. We can monitor the
data on vital statistics over a period of time and estimate the trends and structure of
population growth. Before we explain the implications of this data in population growth,
we will familiarize you with the definitions of some of the important indicators related
to birth, death, disease and fertility. These are briefly summarized in Table 6.3.
Table 6.3: Commonly used terms in vital statistics
Density of population – Number of persons living per square

kilometer area
Infant mortality rate (IMR) – Number of deaths of infants under one year
of age per 1,000 live births
Mortality rate/Death rate – Annual number of deaths per 1,000 population
(CDR)
Birth rate (CBR) – Number of live births per 1,000 estimated mid
year population in a given year.
Fertility rate – The number of children that would be born per
woman, if she were to live to the end of her
child bearing years and bear children at each
age in accordance with prevailing age specific
fertility rates.
Sex ratio – Number of females per 1000 males.
Life expectancy at birth – The number of years new-born children would
live, if subject to the mortality risks prevailing
for the cross-section of population at the time
of their birth.
Net reproduction rate (NRR) – Average number of daughters that would be
born to a woman if she experiences the current
fertility and mortality pattern throughout her
reproductive span (15-49 years).
Maternal mortality rate – Number of death of woman from pregnancy
(MMR) related causes per 100,000 live births.
Under 5 mortality rate – Defined as the number of children dying below
(U5MR) five years / 1000 live births.
Urban population – Percentage of population living in urban areas
as defined according to the national definition
used in the most recent population census
129
Public Nutrition We will now look at some of these different indicators and their implications on trends
and structure of population growth. We begin with birth and death rates.
Birth and death rates
You studied earlier in this unit that in India, the birth rate is showing a declining
trend i.e. reaching a level of 20.4 (SRS 2016)/1000 population in 2016 from 41.7 in
1951. On the other hand, mortality has declined in India from a figure of 109 death
per 1000 live birth from 1992-93 to 50 death per 1000 live births in 2015-16. (NFHS-
4, 2015-16). This has resulted in considerable increase in life expectancy at birth for
both the sexes. The life expectancy at birth has improved from 41.6 years in 1951 to
67.6 years in 2017 for males and corresponding values for females are 40.6 years and
70.1 years. You would also note that there are regional diversity in birth rates between
rural and urban areas and amongst states in India.
Let us find out about this diversity.
Regional diversity - There are great differentials in the crude birth rate (CBR)
between rural and urban areas, in rural areas rates are higher (20.7%), as compared
to urban area (17.5%). As per NFHS-4 (2015-16) data, birth rates are high in states
like Bihar 27.0, Meghalya 24.6, Uttar Pradesh 22.6, Manipur 21.2 and Nagaland 21.4.
Whereas, Kerala (11.2) and Sikkim (11.4) recorded with the lowest crude birth rates.
The factors associated with low birth rates in Kerala is the high literacy rate (97.9%)
of the females and likewise high birth rates in Bihar are due to the poor literacy rates
(49.5%) amongst the women.
Let us review the implication of net reproduction rate on population structure.
Net Reproduction Rate
You studied earlier that Net Reproduction Rate (NRR) is the average number of
daughters that would be born to a woman if she experiences the current fertility and
mortality pattern throughout her reproductive span (15-49 years). NRR is a demographic
indicator. NRR of 1 is equivalent to attaining approximately a 2-child norm.
Demographers believe that the goal of NRR 1 can be achieved only if at least 50
percent of the eligible couples are effectively practicing family planning. According to
the National Health Policy (1983), the long-term goals were to reach NRR of 1 by
2000 A.D., which corresponds to achieving birth rate of 21, death rate of 9 and
growth rate of 1.2. The NRR in India is estimated to be 1.06 (World Population
Prospectus, 2017). A crucial factor responsible for high fertility (3.6 in 1992 and 2.2
in 2015-16) in India is the young age of marriage for girls (19.20 years in 1984). But
now the trend is changing slowly and early marriages has been declined over time. The
median age at first marriage for women increased from 17.2 years in 2005-06 to 19.0
years in 2015-16.
There are considerable regional variations with Kerala reporting the highest mean age
at marriage of years for females. Also, it is higher in urban areas than in rural areas.
Let us review maternal mortality ratio.
Maternal Mortality Ratio
Childbirth, without proper antenatal care and attention during and after delivery has a
high risk. The actual risk of an Indian woman dying from a maternity related cause
could be far more than the developed world because of her larger number of pregnancies
(five or six compared with one or two in the developed nations). Maternal mortality
rate in India is estimated to be 130 per 1,00,00 pregnant women (SRS, 2016). The
major causes of death in childbirth include postpartum haemorrhage, eclampsia in last
stages of pregnancy, infection from an untreated perineal tear and obstructed labour.
All these clinical causes of maternal mortality are related to maternal age, number of
births and malnutrition, particularly anaemia. A woman giving birth to children at the
optimum age of 20-35 years faces much lower average risk than women below 20 and
over 35 years. It is also observed that maternal illness and deaths are significantly
130
more with the fourth pregnancy onwards. The type of care received at childbirth is Population Dynamics
often critical for the health and survival of both the infant and the mother.
Let us now review how infant mortality rate (IMR) and child mortality rate (U5MR)
affects the trends in population growth.
Infant mortality rate (IMR) and Child mortality rate (U5MR)
IMR and U5MR are sensitive indicators of a country’s development and reflect the
quality of life. The infant and under-5 mortality rate in rural areas of our country is
substantially more than in the urban areas where most of the health facilities are
available. A large number of biological, medical, social and economic factors influence
these two rates. The high rate also points to the downward spiral of the interplay
between malnutrition and infections. Infant mortality rate in India is 34 per 1000 live
births (SRS, 2016). It is higher in rural areas (41) as compared to urban areas (25).
But one encouraging factor in IMR is its trend of gradual decline, say from 53 in 2008
to 34 in 2016. The decline is seen in both urban as well is in rural areas.
You would also note large differences in the IMR and U5MR amongst the states.
Major states having high child mortality rate are Uttar Pradesh (64), Chattishgarh (54),
Madhya Pradesh (51), Assam (48), Bihar (48) and Jharkhand (44). On the other hand,
the state of Kerala, has achieved an IMR of 7, a figure comparable to that of any
industrialized country. In Kerala, female literacy is high, medical, educational,
transportation and communication facilities are available within 2 km, for a much large
proportion of population while in Bihar and Rajasthan female literacy is low and there
is inadequate development of health care, education, transportations and communication
facilities. Thus, a high infant and child mortality reflects the poor state of public health,
hygiene and environment sanitation in any country. Figure 6.4 illustrates the key
infant mortality rates by demographic characteristics, 2015-2016 as reported by National
Family Health Survey (NFHS-4).You can see that infant mortality rate is very high
when mother is between the age of 40-49 years of age and has previous birth interval
of less than 2 years.
Figure 6.4: Infant Mortality Rate by Demographic Characteristics (2015-16)

We hope from our discussion above you may have got good idea of how the monitoring
of data on vital statistics can help in assessing and estimating the trends in population
growth and structure. Let us take a break here and recapitulate what we have learnt
so far. Answer the questions given in check your progress exercise 2.
131
Public Nutrition
1. What does a broad base and a tapering top of the ‘age pyramid’ of a country
indicate?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
2. Define the following:
a. Dependency ratio.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
b. Net reproduction rate (NRR)
..........................................................................................................................
..........................................................................................................................
3. Define sex ratio. What does an adverse sex ratio indicate?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
4. List the factors which affect high fertility in India.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
In the section above, we studied about different types of vital statistics and their use
in estimating population growth and structure. You are now aware that India’s IMR,
U5MR and maternal mortality ratio are very high when compared to other developing
countries. India needs to greatly improve on these indicators to improve the quality
of life of its people. Government of India has initiated many policy and programmes,
aimed towards improving the health and welfare of mother and child in the country.
We will learn about the National Policy and programmes on health and population next.
6.6 POPULATION POLICY

In this section, we will briefly review a series of population policy initiatives by
Government of India, beginning 1976 till to date. Population policy refers to policies
intended to decrease the birth rate or growth rate. Statements of goals, objectives
and targets are inherent in population policy. In April 1976, India framed its first
‘National Population Policy’. It called for an increase in the legal minimum age at
marriage from 15 to 18 years for females, and from 18 to 21 years for males. The
1976 policy was modified in 1977 by the then New (Janata) Government. The new
policy statement reiterated the importance of the small family norm, but ruled out all
forms of compulsion and changed the programme’s title to ‘Family Welfare’. The
statement however, endorsed the previous government’s decision to raise the minimum
age at marriage and the birth rate target of 25 per 1000 population by 1984 (which
was not achieved).
132
The National Population policy was than revised in year 2000 with an aim to address Population Dynamics
the family planning, the broadest possible dimensions which includes not only health
and family welfare but also child survival, basic reproductive and child health care,
women’s status and employment, literacy and education, socioeconomic development
and anti-poverty programmes. The long term goal of the policy is to achieve a stable
population by 2045. Some of the highlights of the policy are as follows:
 Address the unmet needs for basic reproductive and child health services, supplies
and infrastructure.
 Mark school education upto age 14 free and compulsory, and reduce drop outs at
primary and secondary school levels to below 20 percent for both boys and girls.
 Reduce infant mortality rate to below 30 per 1000 live births.
 Reduce maternal maternity rate to below 100 per 1000 live births.
 Achieve universal immunization of children against all vaccine preventable diseases.
 Promote delayed marriage for girls, not earlier than age 18 and preferably after 20
years of age.
 Achieve 80 percent institutional deliveries and 100 percent deliveries by trained person.
 Achieve universal access to information/counselling, and services for fertility
regulation and contraception with a wide basket of choices;
 Achieve 100 percent registration of births, deaths, marriages, and pregnancy.
 Contain the spread of the Acquired Immuno-deficiency Syndrome (AIDS) and
promote greater integration between the management of reproductive tract infections
(RTIs) and sexually transmitted infections (STIs) and the National AIDS Control
Organization.
 Prevent and control communicable diseases.
 Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and
child health services, and in reaching out to households; and
 Promote vigorously the small family norm to achieve replacement levels of Total
Fertility Rate (TFR).
 Bring about convergence in implementation of related social-sector programmes so
that family welfare becomes a people-centered programme.
In conclusion, the Government of India has outlined several action ideas in the latest
population policy document, aimed towards overall improvement of the condition of
women and children.
Having looked at Government of India’s population policy and aim to improve the
overall condition of women and children, we can now aim at improving the quality of
life for this vulnerable section of society. So, there is a relationship between fertility,
nutrition and quality of life. As a public nutritionist, it would be useful to understand
this relationship. In the following section, we will explore this relationship.
6.7 RELATIONSHIP BETWEEN FERTILITY,

NUTRITION AND QUALITY OF LIFE
You may have noticed that in many developed countries, women have less children
and these children are mostly healthy, that is, they have good nutritional status and the
family enjoys a good quality of life. So, there must be a relationship between these
three. We would like to have the same scenario for India too. We will now study the
relationship between fertility, nutrition and quality of life. Human Development Index
133
Public Nutrition developed by UNDP takes care of relationship between fertility components, nutrition
and quality of life. Human development is a process of expanding human choices by
enabling people to enjoy long, healthy and creative lives. It is a people-centered approach
to policy making.
A child born today in a developing country can expect to live 16 years longer than a
child born 35 years ago. The infant morality rate has been more than have since 1960.
School enrolment has more than doubled. These are all part of measurement of human
development index. If we want to compute the human development index (HDI), we
require three indicators: longevity, as measured by life expectancy at birth, educational
attainment, as measured by a combination of adult literacy (2/3rd weight and the
combined first, second and third level gross enrolment ratio (1/3rd weight) and standard
of living as measured by Gross Domestic Product (GDP) per capita.
The high fertility in India is attributed to early and nearly universal marriage, larger
family norm, preference for sons, low economic status, illiteracy, higher IMR, agrarian
society, low urbanization and cultural resistance to change. Limiting the family size is
a concern both at national and international level. The advocacy of family planning and
family limitation is essential.
The family planning programme in India is an entirely voluntary programme though

actively supported by extension education and persuasion. Over the years the programme
has developed as an integral part of existing medical and health services, particularly
the maternal and child health services. This has greatly facilitated the expansion of
family planning programmes, first because the antenatal, postnatal and paediatric clinics
provide opportunities for its promotion and secondly, the health personnel in these
clinics are already accepted by local communities. We have read in the beginning of
this unit that population of India is rising, although, at a slower rate. You have also
learnt that excessive population growth is an impediment to socioeconomic development
and therefore affects the quality of life. So how does excessive population growth
adversely affect the quality of life?
In a developing county like India, excessive population growth nullifies the efforts to
improvement of the quality of life of the people. The physical, social and cultural needs
of man, both in quantity and quality are, food, water, air, housing, clothing, education,
employment, medical and health facilities, transportation and entertainment facilities.
The increase in the number of people slows down the social and economic development.
Another dimension of the population problem in the country is food insecurity, under
nutrition and ill health, which is causing a steady deterioration of the physical and
mental capacity of our human resources. So, we must slow down on the population
growth. How does a controlled population growth improve the quality of life?
A small family norm would go a long way in feeding children and caring for their social,
economic and developmental needs. Also a reduction in child mortality would indirectly
affect birth spacing. When an infant survives and is healthy, couples are less likely to
have their next child very soon. Programmes for child health and family planning can
work to encourage people to have longer, healthier birth intervals. The long term
outcome of food security is ultimately reflected in an improvement in the life expectancy
of the population. Increasing life expectancy is a pointer to improving food security in
India. To cite an example in the state of Kerala, the percentage of population with
chronic energy deficiency (CED) is 33.20% and life expectancy at birth was highest
70.90 in 1990.
Thus we conclude that controlled population growth induces the social and economic
development and the availability and accessibility of resources especially food, improves
the mental and physical capacity of the people. This eventually improves the quality of
life.
134
With this we end our study on population dynamics. We hope now you are in a better Population Dynamics
position to appreciated and relate the demographic process to the nutrition, health
status of population groups.
1. What does a population policy refers to?
........................................................................................................................
........................................................................................................................
2. Enumerate the highlights of the 2000 revised population policy.
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
3. What do you understand by the term Human Development?
........................................................................................................................
........................................................................................................................
4. Describe the effect of population growth on the quality of life of people?
........................................................................................................................
........................................................................................................................
........................................................................................................................
6.8 LET US SUM SUP

In this unit we learnt that demography is a scientific study of human population.
There is a demographic cycle of five stages through which a country passes. India
is now passing through third stage or late expanding where the population is still
growing at a high rate and birth rates have begun to fall. India’s population has grown
approximately more than four times from 1991 till 2011. Several factors have contributed
to this growth which include growing urbanization, adverse sex ratio, high birth rate,
high mortality rates among vulnerable section of our population. There is an urgent
need to comprehend the implications of excessive population growth and its effect on
the quality of life of the people and the development of the nation.
6.9 GLOSSARY
CED : refers to chronic energy deficiency produced
within a teritory during a specified period,
regardless of ownership.
Eclampsia : condition associated with hypertension,
proteinuria, generalized oedema, and seizures
with pregnancy or the early post-partum.
GDP : gross domestic product is defined as the total
value of goods and sources.
135
Public Nutrition Obstructed labour : a term used during child birth. Labour is called
obstructed when there is no progress despite
strong uterine contractions.
Postpartum haemorrhage : excessive bleeding after the child birth.
SRS : sample registration system

EXCERCISES
1. The scientific study of human population is termed as ‘Demography’. It focuses
on 3 observable phenomena -
a. Changes in population size (growth/decline)
b. The composition of population
c. Distribution of population in space.
2. The 5 stages of demographic cycle through which a nation passes are:
a. High stationary
b. Early expanding
c. Late expanding
d. Low stationary
e. Declining
3. The year 1921 is called the ‘big divide’ because the absolute number of people
added to the population in India, thereafter, each decade has been on the increase.

1. A broad base and tapering top of the age pyramid of a country reflects that it is
a developing nation and has a higher proportion of dependants compared to active
productive and working population.
2. a. The ratio of the combined age groups 0-14 years plus 65 years and above
to the 15-65 years age group is termed dependency ratio.
b. Is defined as the average number of daughters that would be born to a

woman if the experiences the current fertility and mortality pattern throughout
her reproductive span (15-49 years).
3. Sex ratio is defined as ‘the number of females per 1000 males’. If the sex ratio
is adverse to women, it suggests that the decline in mortality of females has
lagged behind that of males. In addition, it is also affected by sex selective
migration and sex ratio at birth.
4. The high fertility in India can be attributed to
a. Universality of marriage
b. Low age of marriage
c. Low level of literacy
136
d. Poor economic status Population Dynamics
e. Limited use of contraceptives
1. Population policy refers to policies intended to decrease the birth rate or growth
rate. Statement of goals objectives and targets is inherent in population policy.
2. The highlights of the 2000 revised population policy are as follows:
 Address the unmet needs for basic reproductive and child health services, supplies
and infrastructure.
 Mark school education upto age 14 free and compulsory, and reduce drop outs at
primary and secondary school levels to below 20 percent for both boys and girls.
 Reduce infant mortality rate to below 30 per 1000 live births.
 Reduce maternal maternity rate to below 100 per 1000 live births.
 Achieve universal immunization of children against all vaccine preventable diseases.
 Promote delayed marriage for girls, not earlier than age 18 and preferably after 20
years of age.
 Achieve 80 percent institutional deliveries and 100 percent deliveries by trained person.
 Achieve universal access to information/counselling, and services for fertility regulation
and contraception with a wide basket of choices;
 Achieve 100 percent registration of births, deaths, marriages, and pregnancy.
 Contain the spread of theAcquired Immuno-deficiency Syndrome (AIDS) and promote
greater integration between the management of reproductive tract infections (RTIs)
and sexually transmitted infections (STIs) and the NationalAIDS Control Organization.
 Prevent and control communicable diseases.
 Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and
child health services, and in reaching out to households; and
 Promote vigorously the small family norm to achieve replacement levels of Total
Fertility Rate (TFR).
 Bring about convergence in implementation of related social-sector programmes so
that family welfare becomes a people-centered programme.
3. Human development is a process of expanding human choices by enabling people
to enjoy long, health and creative lives. It is a people-centered approach to policy
making.
4. In a developing county like India, excessive population growth nullifies the efforts
to the improvement of the quality of life of the people. The physical, social and
cultural needs of man; both in quantity and quality are food, water, air, housing,
clothing, education, employment, medical and health facilities, transportation and
entertainment facilities. The increase in the number of people slows down the
social and economic development. Another dimension of the population problem
in the country is food insecurity, under nutrition and ill health, which is causing a
steady deterioration of the physical and mental capacity of our human resources.
Therefore, a small family norm would go a long way in feeding children and
caring for their social, economic and developmental needs. Also a reduction in
child mortality would indirectly affect birth spacing. When an infant survives and
is healthy, couples are less likely to have their next child very soon. Programmes
for child health and family planning can work to encourage people to have longer,
137
healthier birth intervals.
Public Nutrition
UNIT 7 ASSESSMENT OF NUTRITIONAL
STATUS IN COMMUNITY SETTINGS-I
Structure
7.1 Introduction
7.2 Nutritional Assessment  Goals and Objectives
7.3 Methods of Nutritional Assessment
7.4 Indirect Assessment of Nutritional Status

7.4.1 Age Specific Mortality Rates
7.4.2 Cause Specific Mortality Rates
7.4.3 Cause Specific Nutritionally - Relevant Morbidity Rate
7.4.4 Ecological Factors
7.5 Direct Assessment of Nutritional Status
7.6 Nutritional Anthropometry

7.6.1 Uses of Anthropometry
7.6.2 Common Measurements Used in Nutritional Anthropometry
7.7 Methods of Assessing Nutritional Status in Individuals

7.7.1 Determination of Nutritional Status using MUAC
7.7.2 Determination of Nutritional Status using Weight and Height
7.8 Methods of Assessment of Nutritional Status of Community
7.9 Let Us Sum Up
7.10 Glossary
7.1 INTRODUCTION
Earlier in Units 3 and 4, we have learnt about various nutritional problems prevalent in our
community. It is important to know the extent and severity of these nutritional problems
so that we can take appropriate steps towards eliminating these problems. The strategy
to determine the extent and severity of nutritional problems is called nutritional
assessment or assessment of nutritional status. In this unit and the next Unit 8, we
are going to learn about different methods of nutritional assessment.
We have already learnt earlier that body weight is one of the most common
indicators used to assess whether a particular individual is well nourished or not.
Likewise, there are several other methods of measuring the nutritional status of
the community. For example, in clinical practice, doctors identify children suffering
from malnutrition by clinical examination. Some biochemical parameters like haemoglobin
is estimated to assess the iron status among individuals. As a dietitian or nutritionist,
you will be required to assess the dietary patterns of individuals or community groups
as a means to assess nutritional status. Quite often, we also use certain vital health
statistics like infant mortality rates, under 5 mortality rates to get a nutritional profile
of our population. We shall learn about these methods i.e. anthropometrical, chemical,
biochemical and diet survey in this unit and the next Unit 8. We shall start our study
138 of nutritional assessment in this unit by focusing on nutritional anthropometry.
Objectives Assignment of
Nutritional Status in
After studying this unit, you will be able to: Community Setting-I
l list goals and objectives of nutritional assessment;

l describe different methods of nutritional assessment;
l discuss indirect methods of nutritional assessment;
l explain the significance of nutritional anthropometry;
l discuss various methods of anthropometric classification; and
l carry out some of the nutritional anthropometric methods.
7.2 NUTRITIONAL ASSESSMENT — GOALS AND

OBJECTIVES
We stated earlier that the strategy to determine the extent and severity of nutritional
problems is called nutritional assessment or assessment of nutritional status. Before
we discuss this further, let us first understand what we mean by the term nutritional
status. Nutritional status, refers to the state of health of an individual as it is
affected by the intake and utilization of nutrients. Thus, nutritional assessment is
done to assess the severity and magnitude of nutritional problems prevalent in
communities due to faulty intake or utilization of nutrients. The major objective of such
an assessment is to determine the type (what?), magnitude (the numbers affected) and
distribution of malnutrition in different geographic areas (where?), identify the at-risk
groups (who?) and to determine the contributory factors (why?). In other words, the
goal of the nutritional assessment of communities is to discover facts about nutritional
situation and guide action to improve nutrition and health. Factual evidence of the exact
magnitude of nutritional problems is essential to sensitize administrators and politicians
to obtain allocation of material and human resources and plan appropriate intervention
strategies. Also, in the formulation of a public health strategy to combat malnutrition,
assessment of nutritional status of community is the first step. There are different
methods of measuring nutritional status. Let us study what they are?
7.3 METHODS OF NUTRITIONAL ASSESSMENT

In our discussion so far we have studied as to why we do nutritional assessment. Next,
let us get to know how we do nutritional assessment. There are certain methods
which are used to conduct nutritional assessment. These methods can be categorized
as Direct Assessment and Indirect Assessment. We would learn about both these
methods in this section. Let us study about direct assessment first.
1) Direct Assessment
In direct assessment, we measure certain indicators on representative samples of
community to determine nutritional status of community. In other words, we can
directly take measurements like body weight or clinically examine or estimate haemoglobin
levels on certain group of individuals. The representative samples of community can
be taken with the help of nutrition survey. We will study about different methods of
direct nutritional assessment a little later in this unit. Let us now look at Indirect
assessment.
2) Indirect Assessment
Under the method of Indirect assessment, a variety of vital statistics are used to assess
nutritional status. These are: 1) mortality rates among vulnerable groups of population
139
Public Nutrition like infant mortality rate or maternal mortality rate, and 2) morbidity rates of conditions
like diarrhoea and respiratory infections etc. to find out whether the community is
adequately nourished or not.
We will begin our discussion on methods of nutritional assessment by first
learning in detail about indirect assessment and review some specific health
statistics data used under this method to assess nutritional status of community. We
will then go over to study about direct assessment. So then, let us get started with
indirect assessment.
7.4 INDIRECT ASSESSMENT OF NUTRITIONAL

STATUS
Nutritional status, we have learnt above, can be assessed by indirect methods such
as mortality rates (i.e infant, maternal and perinatal mortality rates), morbidity rates and
other health statistics. Let us understand what we mean by mortality and morbidity
rates. Mortality rate is defined as the number of deaths in a group of people,
usually expressed as deaths per thousand while morbidity rate is defined as the
number of people ill during a time period divided by the number of people in the
total population. You may recall learning about these statistics in the previous Unit
6 in Section 6.5. Generally, in such cases, data already collected in connection with
other national surveys is utilized for the purpose. The principle is that malnutrition
influences several morbidity rates and mortality rates. In addition, morbidity rates also
influence the nutritional status of vulnerable groups of population particularly young
children.
It should be recognized that quite often collection of accurate data on these rates is
often be set with a lot of problems. Only institutions having sufficient expertise should
collect such data. In India, sample registration scheme collects information regularly
using standardized procedures through trained investigators on statistically adequate
samples. They publish annual reports, which could be used for the purpose. Collection
of morbidity data requires prospective surveys on a statistically adequate sample using
standardized definitions and procedures. Morbidity surveys involve collection of data on
a longitudinal basis by visiting the selected households either weekly or at least fortnightly.
The gap between two visits in a morbidity survey is called as reference period. It is
recommended that this should never be more than a fortnight. Longer the gap, more
will be the recall lapse by the persons providing information. Morbidities like diarrhoea,
acute respiratory infections and measles are commonly associated with malnutrition.
Higher incidence of these morbidities could be considered to lead to malnutrition. In
addition, malnutrition could predispose to some of these morbidities, as the child’s
immunity (ability to fight infections) would have been affected during severe malnutrition.
Some of the specific indirect indicators used to asses nutritional status of community
are: age-specific mortality rates, cause specific mortality rates and cause specific
morbidity rates. Many times, data is also collected on ecological factors which affect
nutritional status of community. Let us study each of these indicators in detail. We
shall start with the mortality indicators first.
7.4.1 Age Specific Mortality Rates

An age-specific mortality rate is a mortality rate limited to a particular age group. The
numerator is the number of deaths in that age group, the denominator is the number
of persons in that age group in the population. Age specific mortality rate is an important
indicator of health status. In areas, where the prevalence of protein energy malnutrition
is high, mortality among children between 1-4 years remains high. Though infant
mortality rate (IMR) is considered as an indicator of health status, it is now recognized
that the 1-4 year mortality rate is several folds higher in developing countries compared
140 to developed countries due to high rates of protein energy malnutrition.
This is also evident by the fact that since independence there has been a considerable Assignment of
reduction in IMR (from about 160 to 60 per 1000 live births). The main reason for Nutritional Status in
Community Setting-I
the high mortality among children 1-4 years is due to the combined effect of nutritional
stress and high morbidity rates during this age period.
Now, where can we collect the data on age specific mortality rates?
We can collect this data by consulting birth and death records, wherever available. In
India, census data collected regularly every decade can also provide such information.
Special surveys could also be organized if necessary expertise is available on statistically
adequate and random samples. However, such surveys are laborious and time consuming
and may not provide any additional information over direct methods of assessment. Let
us look at the second indicator now. i.e. cause specific mortality.
7.4.2 Cause Specific Mortality Rates

The cause-specific mortality rate is the mortality rate from a specified cause for a
population. The numerator is the number of deaths attributed to a specific cause. The
denominator is the at risk population size at the midpoint of the time period.
Data on cause-specific mortality would be extremely useful to determine the nutritional
status of communities indirectly. However, in India, such data is not available in all the
areas and most often is not accurate. Such data can be obtained from health centers
and hospitals. Mortality due to clinically identifiable malnutrition, if records are available,
could be of help to assess indirectly the nutritional status of communities. Hospital
admissions of clinical cases of nutritional deficiencies, particularly of severe protein
energy malnutrition and keratomalacia, also are often used as an indicator of nutritional
status of communities.
We looked at the indicators related to mortality. Now let us look at the indicator on
morbidity i.e. disease.
7.4.3 Cause Specific Nutritionally - Relevant Morbidity Rate

Information on the prevalence/incidence of nutritionally relevant diseases like measles,
diarrhoeas and acute respiratory infections also are indirect indices of nutritional status
at the community level. In clinical settings, most often children with severe forms of
clinical malnutrition have a history of suffering from some of these morbidities before
developing malnutrition. In fact, in the earlier days, epidemics of malnutrition followed
epidemics of measles and diarrhoeas. There are other diseases which also contribute
to malnutrition. Some of these are intestinal helminthiasis, malaria and tuberculosis.
These could also influence the extent of malnutrition in a community. In the present
circumstances, the occurrence of AIDS could be an important determinant of malnutrition.
Therefore, during the field visits, information on these diseases could be obtained from
hospitals and health centers. The cause specific nutritionally relevant morbidity rates,
therefore, serve as an important indirect indicator to assess nutritional status. Let us
now study about some ecological factors which could indirectly indicate the possible
nutritional status of communities.
7.4.4 Ecological Factors

Human malnutrition is recognized to be an ecological problem in the sense that it is the
end result of several overlapping and interacting factors in the community’s physical,
biological and cultural environment. Information on food consumption, particularly infant
and child weaning practices, beliefs and cultural practices, medical and health services;
educational services and socioeconomic conditions of the community will be of use in
the assessment of nutritional status at the community level. We can collect the information
through field visits to the areas. Let us study about some of these factors in a little
detail to see how they could affect malnutrition.
141
Public Nutrition l Breastfeeding and Complementary feeding
Breastfeeding practices like exclusive breastfeeding up to 6 months of age, feeding
of colostrums to newborn children and introduction of complementary food at six
months of age to infants are the most important factors which could improve the
nutritional status of communities. In India, where the prevalence of malnutrition continues
to be high, colostrum is often discarded due to certain taboos (it is impure milk),
complementary food is introduced only after the child completes the age of one year.
In other words, the child is not getting adequate food even from a very young age.
l Food Consumption Practices
Similarly, qualitative information on food consumption could be an indirect evidence for
malnutrition in that community. For example, the practice of consumption of foods like
pulses, green leafy vegetables and milk particularly among young children can indicate
the state of nutrition of the community. In addition, the practice of reducing food
intakes and avoidance of foods during pregnancy, restriction of foods during certain
diseases like during diarrhoea is indicator of poor dietary practices among the community.
l Socioeconomic Factors
Socioeconomic status determines nutritional status. Malnutrition is of higher magnitude
among the poorer groups like scheduled caste and tribe communities people living in
urban slums etc. Apart from poverty, the literacy  particularly female literacy 
among these communities is very low leading to ignorance and food taboos. The living
conditions of these groups is so poor that even if they spend all their incomes on foods,
they still will not be able to meet the nutritional needs. The gender discrimination,
particularly at the social level, could contribute to higher malnutrition among females.
l Health Care Facilities and Practices
The health care facilities as such in the rural areas are not satisfactory and even if
they are available the community most often visits these facilities at a late stage. Most
often, any visit to a health facility, which is situated at some distance means loss of
wages for the household. In addition, the services are not satisfactory due to lack of
accountability among the health functionaries. Assessment of environmental sanitation
and hygiene practices also could indirectly indicate the possible nutritional status of
communities. The information on these factors can be collected through rapid visits
and collection of qualitative data.
From our above discussions, it is clear that factors such as feeding practices, food
consumption patterns, socioeconomic factors and health care practices, can all influence
nutritional status. Remember all these factors are indirect assessment methods.
Thus, we saw that we could use health statistics data and also collect information on
ecological factors to indirectly assess nutritional status of community. We will now
study how we could directly assess the nutritional status of the community. But first
let us recapitulate what we have learnt so far. Answer the check your progress
exercise 1 given next.
1. Mention three main purpose of nutritional assessment.
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
2. What are the different methods of nutritional assessment?
.........................................................................................................................
.........................................................................................................................
142
Assignment of
3. List three health statistics data used for indirect nutritional assessment. Nutritional Status in
Community Setting-I
.........................................................................................................................
.........................................................................................................................
4. List three ecological factors used for nutritional assessment.
.........................................................................................................................
.........................................................................................................................
Now we move on the direct assessment of nutritional status.
7.5 DIRECT ASSESSMENT OF NUTRITIONAL

STATUS
The last section focused on indirect assessment techniques of assessing nutritional
status. We have also studied earlier that we can also directly assess nutritional status
of community. We can directly reach out to the people and conduct nutritional
assessment. How? We can do it in many ways. For example, we can ask people
about their dietary intake, we can take their body measurement or conduct some
biochemical tests. The commonly used methods are:
i. Nutritional anthropometry,
ii. Clinical examination for nutritional signs,
iii. Biochemical estimation, and
iv Dietary assessment.
In this unit, we will learn about the first commonly used method of assessment i.e.
nutritional anthropometry in detail. About other methods, we will learn in the next unit
i.e. Unit 8.
We stated in the beginning of this unit that we measure certain indicators on
representative samples of community to assess the nutritional status of communities
and these representative samples can be taken with the help of a nutrition survey. In
the routine nutrition surveys, clinical examination and nutritional anthropometry form
the most important components, since these are relatively simple in community situations
and do not require any sophisticated equipment like biochemical estimations.
Before we discuss in detail about the different methods of direct assessment of
nutritional status of community, let us learn as to how nutritional deficiency progresses,
which would help us to decide the methods of assessment to be adopted to measure/
identify these changes.
Progression of Nutrition Deficiency Disorder
It is well recognized that the primary cause for nutritional deficiencies is inadequate
dietary intakes for long periods. Such a dietary inadequacy, to start with, leads to
changes in tissues and organs like muscles and liver progressing subsequently to
biochemical changes. While the changes in tissues can be measured by examining the
concerned tissues, examination of the blood and plasma or serum can identify biochemical
changes. At this stage, the nutritional deficiencies are considered as subclinical as we
cannot find any anatomical changes by naked eye examination. These sub clinical
changes can be identified either by biochemical assessment or anthropometry. The
anatomical changes in some of the organs of the body, like swelling in the body or
changes in the eyes, can be diagnosed by clinical examination. Table 7.1 gives a flow
chart indicating methods of assessment to be used as the nutrition deficiency progresses.
It depicts that by conducting a dietary survey, we can assess dietary inadequacy and 143
Public Nutrition as the deficiency progresses, different methods of assessment will indicate changes
at different levels in the body.
Table 7.1: Progression of Nutrition Deficiency Disorder
Progression of Deficiency Methods of Assessment
Dietary Inadequacy  Diet Survey
 
Tissue Changes  Examination of Tissues
 
Biochemical Changes  Biochemical

Assessment
 
Subclinical changes  Anthropometry
 
Anatomical Changes  Clinical Examination
It is important to recognize that the clinically diagnosable forms of nutritional

deficiencies represent only the tip of the iceberg, the bulk of which is under water and
is not visible. It is estimated that for every case of clinical form of protein energy
malnutrition (kwashiorkor/marasmus), there are at least 5-6 cases of moderate to
severe undernutrition. Thus, clinical examination measures only a small proportion of
nutritional disorders and, therefore, other methods of assessment should be
simultaneously used to determine the real magnitude of nutritional deficiencies. This
is important not only to sensitize policy makers and administrators regarding the
importance of malnutrition but also to plan the requirements for any intervention
programmes.
With this basic understanding of the progression of nutritional disorders, let us now
learn what is nutritional anthropometry? What are its uses and what are the common
measurements used in nutritional anthropometry?
7.6 NUTRITIONALANTHROPOMETRY
One of the most important physical changes that occur in undernutrition is growth
retardation. Nutritional anthropometry is the tool which can assess even the early
changes in growth failure.
What is nutritional anthropometry? Nutritional anthropometry is measurement of human

body at various ages and levels of nutritional status. It is based on the concept
that an appropriate body measurement reflects any morphological variation occurring
due to a significant functional physiological change. It is an important component of
any nutrition survey because it is simple, easily measurable by workers with limited
educational qualifications and provides as much information on the nutritional status of
individuals as biochemical parameters. What are the uses of anthropometry? Let us
read and find out in the next sub-section.
144
7.6.1 Uses of Anthropometry Assignment of
Nutritional anthropometry is a very useful tool. It helps in: Community Setting-I
1. assessment of extent of undernutrition of vulnerable groups of population,
2. monitoring of individual children at regular intervals (monthly or quarterly) to find

out faltering in growth (deterioration/no change of growth) to help in early detection
and initiating prompt remedial measures,
3. identification of children who are at risk of undernutrition, to target and prioritize

nutrition action programmes so as to control the extent of undernutrition,
4. mid-term appraisal or terminal evaluation to assess whether intervention programmes

have achieved the objectives, and
5. assessing nutrition rehabilitation of malnourished children under treatment.
Having gone through the points above you would now realize how important nutritional
anthropometry is. We will now study about various body measurements used in nutritional
anthropometry and how they are used in determining the nutritional status.
7.6.2 Common Measurements Used in Nutritional Anthropometry

The methods of the body measurement, you must realize, should be simple and provide
practical information on community. These should be quick to measure, and the easiest
to reproduce, simultaneously providing maximum information concerning a number of
nutritional problems. The most commonly used measurements in routine surveys are:
1. Body weight,
2. Standing height or Crown-heel length,
3. Mid-upper arm circumference, and
4. Body Fat.
Circumference of head and chest are also included in some surveys covering children
less than five years of age. However, in view of their limited usefulness we will discuss
only the four measurements mentioned above. You will now learn the relevance of the
body measurements and the methods of their measurement. Let us start with the first
measurement, that is, body weight.
1. Body Weight
Body weight is the most widely used and the simplest reproducible anthropometric
measurement for the evaluation of nutritional status of individuals. Why ? Let’s find
out.
Why body weight?
Body weight is a composite of all body constituents like body water, minerals, fat,
protein, bone etc and indicates the body mass. One of the advantages of body weight
is that its utility is perceived not only by the health personnel, but also by the community,
both the educated and illiterate alike. It is not uncommon to find several mothers
approaching doctors either because their children weigh less (in their perception) or are
losing weight. Thus, it is easier for the health professionals to provide education to
women about the need for proper nutrition by comparing body weights as well as the
normal weights. Serial measurements (repeated measurements at regular periods) of
weight, as in growth monitoring, are more sensitive indicators of changes in nutritional
status than a single measurement at a point of time. Growth monitoring, as you may 145
be aware, refers to the regular measurement of growth which enables mothers to
Public Nutrition
visualize growth, or lack of it, and obtain specific relevant and practical guidance
to ensure continued regular growth and health of children. Body weight is sensitive
even to small changes in nutritional status, caused by short duration childhood morbidities
like diarrhoea etc. Rapid loss of body weight in children should be considered an
indicator of potential malnutrition. Weight is indicative of short-term malnutrition. On
the other hand, weight may also be fairly quickly regained after appropriate intervention.
Thus, body weight is also a good indicator of nutritional rehabilitation.
How do we measure body weight?

The choice of suitable weighing scales is very important to obtain accurate
measurements of body weight. Two types of weighing instruments are available.
These are 1) Salter Weighing scale, which is a spring balance 2) and Beam or
lever scales as shown in Figure 7.1 (a) and 7.1 (b), respectively. Salter weighing
scale is light and portable and can be hung from a roof or a tree as shown in the
Figure 7.1 (a). The child is placed in the sling and then the weight is recorded.
(a) Salter Scale (b) Beam Scale
Figure 7.1 : Weighing scale
Beam or lever scales with an accuracy of 50 g or 100 g are preferable for taking body
weight, as they are more accurate. In the case of birth weight the accuracy should
be at 20 g. The commonly used ‘bathroom type’ weighing scales are spring balances.
These are not recommended as the springs get stretched and inaccurate from frequent
use. A comparative study of spring type and lever actuated weighing scales indicated
considerable differences in weights. The errors in measurements using bathroom
scales are quite high ranging between 0.5 to 1.5 kg in young children between 1-5
years of age. Beam balances are manufactured in India and have been found to be
reliable and are currently in extensive use in ICDS projects. However, it should be
recognized that all the weighing scales are tested for accuracy with known standard
weights at regular intervals and put out of use as soon as the accuracy is lost. Let
us get to know about the technique of taking weight.
146
Technique Assignment of
Weights should be taken as far as possible with minimal clothing, without shoes and Community Setting-I
without holding any support (in case of children they will be holding the hands of one
of their parents/relatives). In the case of infants and noncoperative children, the weights
could be taken with an elder person carrying the infant/child (usually the mother/
caretaker) and subtracting the weight of the elder to get correct weight. In cold places,
the subjects may be wearing heavy warm clothing as a protection against cold. In such
situations, an average weight of the warm clothing can be obtained which can be
subtracted from the weight of the individual.
Let us go over to the second method i.e. height.
2. Height
Length or height is a very reliable measure that reflects the total increase in size of
the individual up to the moment it is determined. Let us find out why height is used
as an important measure to assess nutritional status.
Why Height?
The height of an individual is influenced both by genetic (hereditary) and environmental
factors. An individual’s maximum growth potential is determined by hereditary factors
(parent’s height). The environmental factors, the most important being nutrition and
morbidity, determine the extent of exploitation of that genetic potential. In other words,
only when there is appropriate environment  optimal nutrition and good health care
 an individual can achieve his/her maximum height. Inadequate dietary intake and/or
infections reduce nutrient availability resulting in growth retardation. During periods of
severe nutritional deprivation, growth of height slows down leading to stunting (short
stature) in an individual. Thus, stunting is a consequence of chronic food deficiency.
Since height is affected only by long-term nutritional deprivation, it is considered an
indicator of chronic or long-duration malnutrition.
Next let us learn about the techniques used for height measurement.
Technique
Standing height is measured by anthropometer rods, which are four-piece chromium
plated portable metal rods with a headpiece with an accuracy of 0.1 cm. Some
companies in Delhi and Hyderabad make such anthropometer rods. A vertical measuring
rod or a wooden scale with accurate divisions could also be used. Figure 7.2 shows
the instrument for taking standing height of children.
Figure 7.2: Child height measurement 147

Public Nutrition Height is taken without shoes with the subject standing erect on a flat surface or the
platform of the weighing scales, with the arms hanging naturally at the sides. The head
should be held comfortably erect, with the lower border of the eye orbit in the same
horizontal plane as the external auditory meatus (hole of the ear). The headpiece of
the anthropometer rod should be held, without much pressure, in the sagittal plane
(central part of head).
In the case of infants and young children who cannot stand or those who do
not cooperate, the height is measured with an infantometer. This is referred to
as recumbent or crown-heel length, which is taken on children below the age of
24 months. Figure 7.3 shows the infantometer for taking recumbent length of the
children.
Figure 7.3: Child length measurement
The child should be laid on the infantometer board with his head touching the fixed
headpiece. An assistant should hold the child’s head in proper position. The investigator
should ensure that the child’s body is straight, and flat; should press the knees and
ankles flat against the board and bring the movable piece of the board flat against the
heels with optimum pressure. The measurement should be read while child is still in
position. It is generally agreed that recumbent length measurements are greater than
stature measurements.
Let us now go over to the third method i.e. mid-upper arm circumference as a
measurement used in nutritional anthropometry.
3. Mid-Upper Arm Circumference (MUAC)

Mid upper arm circumference is a useful indicator of nutritional status of individuals
and communities. How does this measure reflect the nutritional status? Let us find
that out.
Why Mid-Upper Arm Circumference?

Poor musculature and wasting are cardinal features of moderate and severe protein
energy malnutrition in early childhood. Circumferences of mid-upper arm (MUAC)
and calf are recognized to indicate the status of muscle development in the body. The
mid-upper arm is heavily muscled and approximately circular. The mid-upper arm
circumference is considered more feasible as it is easily accessible in any age and sex,
and so is simpler and practical to measure. The MUAC may be useful not only in
identifying malnutrition but also in determining the mortality risk in children. The
148 measurements of MUAC correlate well with weight, weight-for-height and clinical
signs of PEM. When measured along with fat fold at triceps, MUAC, in addition, can Assignment of
be used to calculate mid arm muscle circumference (fat free arm circumference). The Nutritional Status in
Community Setting-I
assumption is that the cross-section of the mid upper arm circumference approximates
a circle, and that the adipose tissue (fat) is evenly distributed around the area. Let us
learn about the technique next.
Technique
The arm circumference is measured with flexible fibre glass tape up to 0.1 cm. It is
taken on the left arm, while hanging freely by the side, at its mid point. The mid point
of the left upper arm is measured by taking first the length of the upper arm  between
acromion process of scapula and the tip of ulna – by flexing the forearm at right
angles. The mid point is marked at half the length with a skin marking pencil/ball pen.
The fiberglass tape is placed at the mid point gently but firmly without disturbing the
contours of the arm in any way. Figure 7.4 gives arm circumference insertion tape and
correct tape position for arm circumference.
Figure 7.4: Measurement of mid upper arm circumference
Let us go to the fourth method of body measurement i.e. body fat.
4. Body Fat
The adipose tissue is distributed over a large number of sites in the body. Subcutaneous
fat constitutes the body’s main store of energy (calorie) reserves. How does the
measure of subcutaneous fat, then reflect the nutritional status. Let us find out next.
Why measure fat?

Close association has been observed between fatness and calorie reserves, and between
muscularity and protein status. This relationship can be used as a tool for assessing the
gross nutritional status of persons at specific stages of life. Usually, in field circumstances,
measurement of fat fold thickness at different sites is more feasible than the sophisticated
densitometry or underwater weighing etc. The thickness of fat at various sites of the
body has good correlation with measures of body fat as determined by autopsy,
densitometry and radiography. Fat distribution in and around the body varies with age,
sex, physiological, nutritional and health status and ethnicity. Of all the measures of
fatness, fat fold at triceps is considered to be the simplest and most feasible in
community surveys. In addition, fat folds are measured at subscapular and suprailiac
regions. Let us learn about the technique of fat measurement next.
Technique
Fat fold at triceps is taken at the same point where mid upper arm circumference is
taken. Skinfold calipers like the one shown in Figure 7.5 is used to measure skinfold
thickness.
149
Public Nutrition
Figure 7.5: Measurement of fat fold using skinfold calipers
Various types of skin fold calipers (Harpenden/Lange skin fold calipers) are available
in the market. These are mostly imported. One of the important factors to be considered
while selecting the calipers is that the pinch area should be 20-40 mm2 with an
accuracy of 0.1 mm and should exert a constant pressure of about 10 g/ mm2. The
fat fold measured consists of a double layer of skin and fat. The measurement is
made with the arm hanging loosely by the side. The fat fold parallel to the long axis
is picked up between thumb and fore finger of the left hand without including any
underlying muscle and the measurement taken with the calipers. An average of three
measurements is recommended.
Now that we have learnt about how to take the correct body measurements, we
should find out how we can assess nutritional status with these measurements. Before
we move on to this topic, let us review our understanding of what we have learnt so
far; by answering the questions given in check your progress exercise 2.
1. Mention various methods of direct assessment of nutritional status.
........................................................................................................................
........................................................................................................................
........................................................................................................................
2. List four uses of anthropometry.
........................................................................................................................
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........................................................................................................................
........................................................................................................................
3. What are the common measurements used in nutritional anthropometry?
........................................................................................................................
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150
Now, first, we would learn how to assess nutritional status in individuals (includes Assignment of
children and adults), then we will learn how to assess nutritional status in community. Nutritional Status in
Community Setting-I
7.7 METHODS OF ASSESSING NUTRITIONAL

STATUS IN INDIVIDUALS
Before we learn about how to assess nutritional status in individuals and community,
there are two more important aspects which we need to consider. These are correct
age of the child and the growth reference values. Accurate age of the child should
be assessed for comparison with known growth standards, which can only help in the
diagnosis of undernutrition. Let us learn about how we can assess the correct age
of the child and how do we select the growth reference values for comparison.
l Age Assessment
You probably know that persons living in the rural area and urban slums in India often
are ignorant of their accurate age. More exact assessment of age (up to the month,
if possible) is required particularly in children to assess protein energy malnutrition.
Only a few can produce documentary evidence like either birth certificates or
horoscopes. However, in India, fortunately the age assessment can be done fairly
accurately with the help of a calendar based on local events. In India, several festivals
take place almost every month. In the villages, the farmers also remember lunar
months or the periods of sowing or harvesting of different crops. Before undertaking
any nutrition survey therefore, a calendar of festivals and other events that have
occurred during the previous 5-6 years is prepared and used to assess the age of
children. The mother is asked to relate the birth of her child to one of the festivals or
important local events, and the number of such events the child would have celebrated
since birth is determined. With the help of such a calendar of local events, it is possible
to assess the age fairly accurately. The age of older children is assessed in relation
to the age of the younger child. The mother will be able to tell as to how old was the
elder child when the younger child was born. In areas where the gap between
children is so small, it is often not difficult to assess the age of older children, at least
in terms of completed years.
l Growth Standards
Once we have taken the weight and height of the children and assessed the correct
age, we would want to compare these with a standard called reference data sets so
that we are able to assess the grade or extent of malnutrition. These standards also
known as “frame of reference” are obtained by measuring cross-sectionally (at one
point of time) a statistically adequate sample of healthy and well-fed children of
various ages, whose ages are known accurately. It is recommended that these be
based on normal children, as defined above, of the same area. Therefore, what we use
are the standards developed by World Health Organization (WHO).The new WHO
standards, developed on the results of the Multicentre Growth Reference Study (MGRS)
and published in 2006, now has replaced NCHS standard.
The MGRS data provide a solid foundation for developing a standard because they are
based on healthy children living under conditions likely to favour achievement of their
full genetic growth potential. Furthermore, the mothers of the children selected for the
construction of the standards engaged in fundamental health-promoting practices, namely
breastfeeding and not smoking.
A second feature of the standard that makes it attractive as a basis for an internationally
applicable standard is that it included children from a diverse set of countries : Brazil,
Ghana, India, Norway, Oman and the USA.
These are also referred to as international standards. You should also be familiar
with the concept of percentiles before you use the growth charts. Percentile is the
numerical value of a child in a series of hundred children arranged in an
ascending order. In other words, 50th percentile is the value of the fiftieth child in 151
Public Nutrition such a series and is also known as median. Equal number of children will be either
above or below the 50th percentile. Similarly 10 th percentile means that 10 percent of
children are below the value and 90% are above this value.
Table 7.2 gives the median values (or 50th percentile values) for height and weight as
given by WHO.
Table 7.2: Heights and Weights of boys and girls (0-60 months) —
WHO Median values
Age Boys Girls
(Mo) Height Weight Height Weight
(cms) (kg) (cms) (kg)
0 49.9 3.3 49.9 3.2
6 67.6 7.9 65.7 7.3
12 75.7 9.6 74.0 8.9
18 82.3 10.9 80.7 10.2
24 87.1 12.2 85.7 11.5
30 91.9 13.3 90.7 12.7
36 96.2 14.3 95.7 13.9
42 99.9 15.3 99.0 15.0
48 103.3 16.3 102.67 16.1
54 106.7 17.3 106.2 17.2
60 110.0 18.3 109.4 18.2
Source: The WHO (2006) Child Growth Standards.
We can express the weight and height of children as % of WHO values. For example,
if we have a 18 month old girl weighing 8.5 kg, and if we want to express her weight
as % of WHO values. Then first we will find out the WHO median weight for a 18
month old girl from the Table 7.2. The reference median weight as you can see in
Table 7.2 for 18 months old girl is 10.2 kg. Thus, the weight of the girl as %
expressed of WHO median weight would be = 8.5/10.2×100 = 83.3%.
Tables providing the WHO standard measurement values can be access through
internet source : http:/www.who.int/childgrowth/standard/in.
We have learnt about two important component for growth assessment i.e. how to
find out the correct age and how to select and use the growth standards. Also, earlier,
we learnt about how to measure weight, height, MUAC and skinfold thickness, so
now you are ready to learn how to determine the nutritional status of children based
on these measurements. Let us first start with MUAC
7.7.1 Determination of Nutritional Status using MUAC

How do we determine nutritional status using MUAC as a body measurement? Let
us find out.
The arm circumference increases rapidly from birth to one year, from 11 cm to 16
cm. Between the first and fifth birthdays, it remains fairly constant at about 16 to 17
cm among well-nourished children. During this time, the fat of early infancy is replaced
by muscle. A value of 16.5 cm is the reference cut off point used as a standard.
152 Table 7.3 gives classification for grades of malnutrition for MUAC.
Table 7.3: Classification for grades of malnutrition for MUAC Assignment of
S.No. MUAC (cm) Category Community Setting-I
1. > 13.5 Normal

2. 12.5-13.5 Possible mildly malnourished
3. <12.5 Severely malnourished requires
immediate attention
If the MUAC measurement is about 13.5 cm or more, the child is classified as normal
and if it is less than 13.5, the child is malnourished. Therefore, using the techniques
explained in section 7.6.2, we can measure the MUAC and compare the results with
the reference given in Table 7.3.
Let us now go over to how we determine nutritional status using weight and height.
7.7.2 Determination of Nutritional Status using Weight and Height
Relatively speaking, weight, height and MUAC have come to be considered the most
sensitive parameters for assessing nutritional status of children under the age of six
years. Several methods have been suggested for the classification of nutritional status
based on these measurements. The heights and weights can be expressed in a number
of ways in relation to reference data. These include: (a) by the use of mean and
standard deviation values, and (b) by calculating percentages of the median value of
reference population which is assigned as 100 percent. You might recall learning
about different methods of classification of malnourished children in Unit 3. We will
just recapitulate these here.
Various methods have been suggested to classify children into various nutritional grades
using the body weights alone or in combination with standing height/recumbent length.
In addition, a method of classification to assess nutritional status of adults is also
suggested. These methods are highlighted in Table 7.4. You may recall reading about
these methods earlier in Unit 3, Section 3.2, Sub-section 3.2.1.
Table 7.4: Methods of classification to assess nutritional status of
adults and children
S. No. Method of Classification
Children Adults
A. WHO Classification (Z-Score
or Standard Deviation Classification)
Body mass index
B. Indian Academy of Paediatrics
(IAP) Classification
Let us start with methods of classification suggested for children. We will start with
WHO classification.
A. WHO Classification
WHO classification is based on weight and height both.
Normal growth is considered to encompass values within two standard deviations of
the mean (2SD). Standard deviation is a measure of dispersion or variation in
measurements. The World Health Organization recommends use of this classification
to assess the extent of malnutrition in children.
The standard deviation classification comprises of:
l Weight-for-age (underweight),
l Height-for-age (stunting), and
l Weight-for-height (wasting)
l Body Mass Index (BMI) 153
Public Nutrition Let us understand these concepts in greater details.
l Weight-for-age: Weight-for-age is a commonly used indicator of body size,
and it reflects the level of food intake. The relative change of weight with age
is more rapid than that of height and is much more sensitive to changes in the
growth pattern of the individual. Significant changes can be observed over periods
of few days. Therefore, unlike height-for-age, weight-for-age is a very sensitive
measure of short duration malnutrition. The weight of children should be recorded
regularly to check if there is regular gain in weight. The weight, recorded can
then be compared with standard values or alternatively the weight can be plotted
against age on a graph, to see if the pattern of growth is normal (by comparing
it with the normal curve).
A LOW WEIGHT-FOR-AGE is called UNDERWEIGHT.
This classification is currently used by the ICDS for selecting beneficiaries and for growth
monitoring.
The word ‘Monitoring’ means ‘keeping a close watch’. Growth monitoring, therefore
means keeping an eye on physical growth in terms of height and weight of a person
or groups of persons. In the context of the ICDS programme, growth monitoring, in
fact is weight monitoring of children. Weight is a good indicator of a child’s growth.
Since it is simpler to measure and interpret than height, it is used in the Anganwadi
centre for watching the progress of the child’s health/nutritional status. This monitoring
is done with the help of special growth charts which are separate for boys and girls.
These are also known as weight-for-age charts. As shown in the Figure 7.6(a) and
7.6(b) the curved lines printed on the growth charts helps in interpret
the plotted points which represent a child’s growth status. The line labeled 0 on
chart represents the median, which is, generally speaking, the average. The other
curved lines are z-score lines, Z-score lines are numbered positively (1, 2, 3)
or negatively (-1, -2, -3). In general, a plotted point that is far from the median in
either direction (for example, close to the 3 or -3 z-score line) may represent a
growth problem, although other factors must be considered, such as the growth trend,
the health condition of the child and the height of the parents. For example, if the trend
line of a child continues to decline and crosses the cut-off line -2 z-score than the
child fall into the under weight category. The growth charts are utilized to educate the
mothers regarding the health status of their children and the growth pattern. And more
important, they help the mother/anganwadi worker to quickly identify signs of
malnutrition and take prompt action.
Weight-for-age is an indicator of undernutrition. The classification is given in Table 7.5.
Table 7.5: WHO classification for weight-for-age
Grade of SD Cut-off
Undernutrition (Weight-for-age)
Normal  2 SD
Underweight  2 SD
Severely Underweight  3 SD
l Height-for-age (Stunting): Height-for-age is a measure of stunting. It is well

known that height-for-age is less only when children are exposed to malnutrition
over a long period. The extent of height deficit in relation to age may be regarded
as a measure of the duration of malnutrition. Therefore, stunting is considered as
an index of long duration of malnutrition. Using height-for-age of WHO
standards children can be classified into different grades of stunting. The
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recommended classification is given in Table 7.6.
Assignment of
Community Setting-I
Figure 7.6: (a) Revised Growth monitoring Charts for girls as per the New
WHO Child Growth Standards
Figure 7.6: (b) Revised Growth Monitoring Charts for boys

as per the New WHO Child Growth Standards 155
Public Nutrition
Table 7.6: WHO Classification for height-for-age
Grade of Stunting SD Cut-off (Height-for-age)
Normal  2 SD
Stunting  2 SD
Severe stunting  3 SD
Using this table, we can grade the children as normal or stunted.
It is not uncommon to find considerable percentage of rural children appearing as

apparently normal. When their ages are assessed it would be apparent that these
children are stunted. These children are actually nutritional dwarfs and require
intervention.
l Weight-for-Height (wasting): A measure of weight against height is an indicator

of wasting. It is also common to observe a large number of children who are
wasted and emaciated. Wasting is considered as an index of short duration
undernutrition. In other words, even in middle and high-income group of children,
an exposure to common childhood morbidities like diarrhoea, respiratory infections
and measles can lead to weight loss and wasting. The commonly used weight-
for-age classification does not take into account the changes in weight due to
variations in height/length. Weight is related to height and it is therefore necessary
to take into account the same particularly to assess wasting. Tables of weight-
for-height (also believed to be age independent) are available based on the
measurements of height and weight, of a large number of normal and healthy
children. Weight-for-height less than 2SD of WHO standards is considered to
indicate wasting in preschool children. As in the case of height and weight, all the
values less than 3 SD of WHO standards are considered to indicate severe
wasting. Table 7.7 gives WHO classification for weight-for-height.
Table 7.7: SD classification for weight-for-height
Grade of Wasting SD Cut-off (Weight-for-Height)
Normal  2 SD
Wasting  2 SD
Severe wasting  3 SD
Weight-for-height is also a good prognostic indicator of severe malnutrition, and has

often been considered as a good index of current nutritional status.
Another indicator to assess malnutrition in children is body mass index for age (BMI).
l BMI-for-Age: The ratio of weight (in kg)/height (m)2 is referred to as Body Mass
Index (BMI). Body Mass Index for age is another index for assessment of nutrional
status of children (5-19 years) in terms of both over nutrition and undernutrition. In children
BMI is age and sex specific because the amount of fat varies with age and between boys
and girls. Table 7.8 presents the BMI-for-age percentile values for Boys and Girls aged
5-19 years (WHO Growth Standards 2006).
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Table 7.8: BMI-for-age for boys and girls between 5 to 19 years (Percentiles) Assignment of
Age(years) BMI (kg/m2 ) Community Setting-I
Boys Girls
2 16.0 15.7
3 15.6 15.4
4 15.3 15.3
5 15.2 15.3
6 15.3 15.3
7 15.5 15.4
8 15.7 15.7
9 16.0 16.1
10 16.4 16.6
11 16.9 17.2
12 17.5 18.
13 18.2 18.8
14 19.0 19.6
15 19.8 20.2
16 20.5 20.7
17 21.1 21.0
18 21.7 21.3
19 22.2 21.4
Source : WHO (2006) Child Growth Standards.

http://www.Who.int/child who2007_bmi_for_age/en/index.html. of adolescents.
After the cessation of linear growth around 21 years, weight-for-height indicates muscle
fat mass in the adult body. It, therefore, provides a reasonable indication of the nutritional
status of adults. The BMI has a good correlation with fatness (over weight or obesity).
In the case of adults, the following classification suggested WHO as given in Table 7.9
is extensively used at present.
Table 7.9: BMI classification for adults

Category BMI (kg/m2)
International Asian Population

Underweight <18.5 <18.5
Normal 18.5-24.9 18.5-22.9
Overweight 25.0-29.9 23.0-24.9
Obese 30.0 25
Class I obesity 30.0-34.9
Clas II obesity 35.0-39.9
Class III obesity >40 157
Public Nutrition Table 7.9 shows BMI ranging from 18.5 - 23 is normal, BMI <18.5 indicates chronic
undernutrition, while more than 23.0 is considered as an indicator of overweight/obesity
in Asian Population.
Let us move on to the next method of classification suggested for children.
B. Indian Academy of Pediatries (IAP) Classification
In India, the classification of Children, which is extensively used to group children into
various grades of malnutrition is one proposed by Indian Academy of Paediatrics. You
may recall about it from the Unit 3 under the Section 3.2 and Sub-section 3.2.1.
The discussion above focused on how to determine the nutritional status of individual
children and adults. Now, let us learn how to determine nutritional status of community
or community groups.
7.8 METHODS OF ASSESSMENT OF NUTRITIONAL

STATUS OF COMMUNITY
We learnt about various methods to classify the grades of malnutrition for individual
children. Now, how do we assess the grade of malnutrition for a community itself,
where all these children reside? For this purpose, we use what is known as Distance
charts/Percentile Charts.
At the community level, the means/medians (averages) of the weight and height
measurements are compared with those values obtained on standards of corresponding
ages. These can be plotted on growth chart plotted with the standards of reference.
Such charts are known as distance charts, and indicate the growth pattern of the
community in relation to normal children. It is common to use percentile charts for the
purpose. Surveys carried out in different parts of the country indicate that, on the
average, an average Indian child corresponds to the 5 th percentile of NCHS standards.
In other words, an average Indian child has measurements of weight/height corresponding
to the lowest 5% of American children. Thus, distance charts are the simplest tools
to assess the nutritional status using anthropometry.
So, we learnt about nutritional anthropometry as one of the methods to directly assess
nutritional status of individuals and community in this unit. In the next unit, we will learn
about other methods of direct assessment of nutritional status. Now, let us recapitulate
what we have learnt so far.
1. List methods of classification for nutritional status suggested for children.
..........................................................................................................................
..........................................................................................................................
2. List the method for assessing nutritional status of adults.
..........................................................................................................................
..........................................................................................................................
3. Activity
The following are the weights obtained on a group of children. Distribute them
according to Indian Academy of Paediatrics. Hint: Express the values as %
of WHO weight-for-age provided in Table-7.2.
S.No Age Sex Weight % of WHO Value
(months) (kg) for Weight-for-Age
1 12 Boy 6.2
2 18 Girl 9.8
3 36 Boy 10.9
4 42 Boy 14.5
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Assignment of
7.9 LET US SUM UP Nutritional Status in
Community Setting-I
This unit focused on two methods of assessment of nutritional status. These are
indirect assessment and direct assessment methods. Indirect assessment of nutritional
status can be done by using mortality, morbidity data and ecological data. Some of the
data used for this purpose are age specific mortality rate, cause specific mortality rate,
cause specific nutrition  relevant morbidity rates and feeding practices in children.
Direct assessment method involves using certain indicators like weight, height etc. on
representative sample of community to measure nutritional status. Methods used to
directly assess nutritional status are: Nutritional anthropometry, Clinical assessment,
Biochemical assessment and Dietary assessment. This unit focused in detail on
Nutritional anthropometry. Nutritional anthropometry is a measurement of human body
at various ages and levels of nutritional status. The body measurement commonly
used in nutritional anthropometry are weight, height, mid upper arm circumference
and body fat. These measurements are then compared with a frame of reference to
classify individuals under different grades of malnutrition.
7.10 GLOSSARY
Anthropometry : the field that deals with the physical dimensions,
proportions, and composition of the human body, as
well as the study of related variables that affect them.
Prospective survey : a survey in which the disease or outcome has not
occured at the time the investigation begins.
Stunting : shortness in length or height in the body.
Triceps : a muscle found in upper arm region.
Wasting : thinness or emaciation in the body.

EXCERCISES
1. Three main purpose of nutritional assessment are:
i. To identify facts about nutrition situation and guide action to improve nutrition
and health
ii. To sensitize politicians and administrators
ii. To formulate public health strategy
2. Different methods of nutritional assessment are direct and indirect nutritional
assessment.
3. Three health statistics data used for indirect nutritional assessment are age specific
mortality rate, cause specific mortality rate and cause specific nutritional relevant
morbidity rates.
4. Three ecological factors used for indirect nutritional assessment are:
i. Breastfeeding and complementary feeding
ii. Food consumption data, and
iii. Socio economic profile.
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Public Nutrition Check Your Progress Exercise 2
1. Various methods used to directly assess nutritional status are:
i) nutritional anthropometry, ii) clinical assessment iii) biochemical assessment,
and iv) dietary assessment
2. Uses of Anthropometry are listed as follows: Nutritional anthropometry is a very
useful tool. It helps in:
l assessment of extent of undernutrition (2SD of NCHS reference values)
of vulnerable groups of population
l monitoring of individual children at regular intervals (monthly or quarterly)
to find out faltering in growth (deterioration/no change of growth) to help in
early detection and initiating prompt remedial measures.
l identification of children who are at risk of undernutrition, to target and
prioritize nutrition action programmes so as to control the extent of
undernutrition.
l mid term appraisal or terminal evaluation to assess whether intervention
programmes have achieved the objectives.
3. The most commonly used measurements in routine surveys are a) Mid-upper arm
circumference; b) Body Fat; c) Body weight and d) Standing height or Crown-
heel length.
1. Methods of classification for assessing nutritional status of children are: Indian
Academy of Pediatrics and WHO.
2. Method for assessing nutritional status of adults is Body Mass Index (BMI)
3. Activity: The weights expressed as % of WHO values for weight-for-age are.
S.No. % of WHO Values for Weight-for-Age
1. 64.58
2. 96.07
3. 76.22
4. 94.77
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Assessment of Nutritional
UNIT 8 ASSESSMENT OF NUTRITIONAL Status in Community
Settings-II
STATUS IN COMMUNITY
SETTINGS-II
Structure
8.1 Introduction
8.2 Clinical Assessment
8.2.1 Training and Standardization
8.2.2 Clinical Signs of Nutritional Disorders
8.3 Biochemical Assessment

8.3.1 Biochemical Tests - An Overview
8.3.2 Biochemical Tests for Nutritional Deficiencies
8.4 Dietary Assessment

8.4.1 Family Diet Surveys
8.4.2 Individual Diet Surveys
8.4.3 Qualitative Diet Surveys
8.4.4 Institutional Diet Surveys
8.4.5 Food Balance Sheets
8.5 Let Us Sum Up

8.6 Glossary
8.1 INTRODUCTION
In the previous unit, we learnt about different methods of indirect and direct assessment
of nutritional status of individuals and communities. We learnt that there are four
methods to assess nutritional status under direct assessment. These are: 1) nutritional
anthropometry 2) clinical assessment 3) biochemical tests, and 4) dietary assessment.
Unit 7 focussed on the various methods used under nutritional anthropometry. We now
know that nutritional anthropometry is extensively used for individuals or in communities
to assess the extent of malnutrition. Apart from nutritional anthropometry, clinical
assessment and biochemical tests are also important. In addition, assessment of dietary
intakes of individuals or families provides important information as to the dietary status
of community. In this unit, we would continue our study of nutritional assessment
methods by learning about clinical assessment, biochemical tests and dietary assessment
as the other three methods of direct assessment of nutritional status.
Objectives
l enumerate the methods of direct nutritional assessment namely, clinical assessment,
biochemical tests and dietary assessment;
l describe the clinical signs of various nutritional disorders;
l discuss the advantages and limitations in biochemical tests in field surveys;
l explain various methods of dietary assessment; and
l plan and implement dietary surveys.
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Public Nutrition
8.2 CLINICAL ASSESSMENT
Clinical examination is one of the common tools used to assess the extent of clinical
forms of undernutrition. In the following section, we will discuss about clinical examination
and also know about the common clinical signs of various nutrition disorders utilized
in nutrition surveys. Before we go into details about clinical signs, we should know that
training of the staff assessing clinical signs is very important. Let us find out in detail
about the training and standardization procedures.
8.2.1 Training and Standardization
Trained workers only should carry out clinical examination and it should be done in
good light. All the investigators should undergo rigorous training so that there is complete
agreement in the diagnosis of signs between individuals and between two examinations
of a subject by the same investigator. We should record only the presence or absence
of a particular sign. Any grading of any clinical sign (like + or ++ etc) should be
scrupulously avoided. We should look for the presence of all the signs of commonly
occurring nutritional deficiency so that nothing is missed. For the purpose, a schedule/
proforma should be prepared including all the clinical signs to ensure no deficiency
sign is missed. You might recall that we studied about clinical signs of various
nutritional disorders in Unit 3. Can you recall these signs and symptoms? List these
signs/symptoms in the proforma given herewith including all the clinical signs you
learnt in Unit 3.
Proforma for reporting nutritional deficiency disorders and signs and symptoms
Nutritional deficiency disorders Signs and symptoms
Are you having trouble in recapitulating all the deficiency signs and symptoms? Well
do not panic! Here, in the next section, you will once again find information on clinical
signs and symptoms. So review the section below and get back to the proforma later.
8.2.2 Clinical Signs of Nutritional Disorders

What do we mean by clinical signs? Clinical signs are changes in the body which
are indicative of nutritional deficiency / excess. In this section, we are briefly going
to recapitulate the clinical signs of the following nutritional disorders:
---- Protein energy malnutrition ---- Vitamin C deficiency
---- Vitamin A deficiency ---- Rickets
---- Anaemia ---- Essential fatty acid deficiency
---- Goitre ---- Vitamin B complex deficiency
162 ---- Fluorosis

Let us begin with protein energy malnutrition. Assessment of Nutritional
Status in Community
Settings-II
A. Protein Energy Malnutrition
You are aware that the clinical forms of protein energy malnutrition (PEM)
are kwashiorkor, marasmus and marasmic-kwashiorkor. We will now review the
clinical signs of these three forms of PEM? You may find this information
repetitive, but it is important we recapitulate there clinical signs here. Let us begin
with kwashiorkor.
a. Kwashiorkor
It is more common among children of 1-3 years of age. The most important sign
without which a diagnosis of kwashiorkor should not be made is presence of oedema
(swelling of the body). The swelling is present mostly in the extremities particularly the
lower extremities (legs and feet). The investigator can confirm the presence of oedema
by applying pressure with the thumb over the skin just above the ankle or feet for a
few seconds. It would leave a depression, when thumb is removed, the impression
will disappear. In a normal child who does not have any oedema, no such impression
would occur.
Children with kwashiorkor are always apathetic and often irritable showing no interest
in their surroundings. Their skin and hair (flag signs) may show changes. Kwashiorkor
may be associated with other deficiencies and infections. Let us now discuss clinical
signs of marasmus.
b. Marasmus
Marasmus is characterized by extreme wasting of muscle and subcutaneous fat.
The child is very thin, with skin loosely hanging and appears to have nothing but
skin and bones. The child has an old man’s face and is extremely weak with little
strength even to cry. The body weight could be as low as 50% of standard weight
for age. Hair will be thin and sparse. The child may be associated with diarrhoea and
other infections.
Let us now discuss clinical signs of marasmic kwashiorkor.
c. Marasmic kwashiorkor
Sometimes a child may suffer from clinical signs of both marasmus and kwashiorkar,
this child may be having marasmic kwashiorkar. Marasmus with associated oedema is
called as marasmic kwashiorkor. The child therefore would be emaciated and will also
have oedema.
Let us go to clinical signs of vitamin A deficiency.
B. Vitamin A deficiency
Deficiency of vitamin ‘A’ leads to changes in eyes (ocular signs). The ocular lesions
 also known as xerophthalmiacan be of milder nature, such as night blindness,
changes in the white of the eye like conjunctival xerosis or bitot’s spots. The severe
lesions of eye affect the black of the eye (cornea). These are corneal xerosis, corneal
ulcer or keratomalacia, which ultimately results in permanent loss of vision. Let us
review these manifestations.
a. Night Blindness
Night blindness is the earliest symptom of vitamin ‘A’ deficiency in preschool children.
The affected child cannot see properly at dusk. Often, an attentive mother can recognize
the child’s inability to see the plate of food or toys in ill-lit room.
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Public Nutrition b. Conjunctival Xerosis
Conjunctival Xerosis is recognized by dryness of the conjunctiva, which also becomes
thick and wrinkled. It appears rough instead of being smooth and glistening. The
dryness becomes more obvious when the conjunctiva is exposed to air for 10-15
seconds by keeping eyelids drawn back.
c. Bitot’s spots
These are dirty white, foamy and raised spots on the surface of the conjunctiva,
generally seen on the outer side of the cornea. Look up Figure 3.3(a) in Unit 3. Bitot
spot may appear as a single spot or as several small spots, which may later unite to
form a large triangular patch with base towards cornea. Bitot’s spots will be stained
black when the children use ‘Kajal’. The Bitot’s spots may appear in only one eye or
both the eyes.
d. Corneal Xerosis
This is a manifestation of severe Vitamin ‘A’ deficiency, in which the cornea loses its
normal smooth and glistening appearance and becomes dry and rough. Due to inability
to see bright light, the child tends to keep the eyes closed and, hence, the condition may
be missed during the clinical examination, if not observant.
e. Corneal ulcer
Corneal xerosis, if not treated promptly, leads to ulceration of the cornea. Initially, the
ulcer may be shallow, and if it becomes deep, it may lead to perforation resulting in
prolapse of contents of the eyeball.
f. Keratomalacia
This is a condition of rapid necrosis and liquefaction of full thickness of cornea, leading
to prolapse of iris, resulting in permanent blindness. Vitamin ‘A’ related corneal
involvement (ulcer/keratomalacia) could be differentiated from other infective conditions
of the eye, by the fact that it is painless and the conjunctiva will be muddy white. In
infective conditions, the eye will be red and swollen.
g. Corneal Scar
The ulcer of the cornea, on healing, leaves a white scar, which may vary in size
depending upon the size of the ulcer. When the scar is big or positioned centrally,
normal vision is affected.
Let us now go over to clinical signs of anaemia.
C. Anaemia
Child with anaemia is less active than the normal child. The child may be pale and if
the condition is severe, he/she will be breathless and will have swelling of face, body
and limbs. The best way to detect anaemia is by examining the inner side of the
eyelids, buccal mucosa (top of the roof of the mouth) and nail beds. They appear pale.
Similar signs and symptoms also exist among adults, especially in pregnant and lactating
women with anaemia. In severe condition, the nails of fingers and toes become papery
thin and bend upwards to assume the shape of a spoon. This condition is known as
“koilonychia”. Haemoglobin estimation in blood is the best way for the diagnosis of
anaemia.
Let us review clinical signs of goiter, which is the deficiency of iodine.
D. Goitre
Goitre, deficiency of iodine, manifests as enlargement of thyroid gland situated in the
front of the neck. In normal subjects, thyroid gland is neither visible nor palpable. In
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iodine deficiency, as you may recare seeing in Figure 3.4 earlier in Unit 3 it tends to Assessment of Nutritional
enlarge in size. A thyroid gland when enlarged to a size of greater than the terminal Status in Community
Settings-II
phalanx of the thumb will be considered as goitrous. Other ill effects of iodine deficiency
disorders include cretinism (physical and mental retardation), deaf mutism (deaf and
dumb).
E. Vitamin B complex deficiency
Under this, we will review two most common types of vitamin B complex deficiencies
- riboflavin and niacin deficiency. Let us review the riboflavin deficiency first.
- Riboflavin deficiency
Angular stomatitis, cheilosis, red or magenta tongue, atrophic papillae, and dyssebacea
are signs of riboflavin deficiency.A review of there clinical symptomo follows:
a. Angular Stomatitis
Ulcers at the angles of the mouth, with fissures, are characteristic of this vitamin
deficiency. The fissures may be shallow or deep confined to the angles of the mouth.
They may extend into the oral cavity and also on to the skin outside. Milder lesions
are identified easily with the mouth half-open.
b. Glossitis
The tongue appears bright red or magenta in colour with or without fissures as you
may have observed in Figure 4.1(a) in Unit 4 earlier. The condition is often painful.
The tongue may become completely bald in B complex deficiency.
c. Cheilosis
The lips become red and may develop painful fissures and may sometimes get even
ulcerated. Let us now look at the niacin deficiency.
- Niacin deficiency (Pellagra)
Deficiency of niacin, leads to photo dermatitis (changes in the skin) on the parts of
the skin exposed to sunlight, such as cheeks, neck, waist, hands and feet. In acute
cases, the affected skin may appear red, slightly swollen and cracked, causing itching
and burning sensation. In chronic cases, the skin becomes dry, rough and thick with
brown pigmentation. Red and raw tongue with fissures and atrophic papillae are also
seen in niacin deficiency.
Let us now review the clinical signs of vitamin C.
F. Vitamin C deficiency
Spongy bleeding gums
Gums are swollen (spongy) and bleed with even slightest touch. There may be associated
petechial haemorrhages, ecchymosis and painful epiphyseal enlargement of bones.
We will now review the clinical signs of deficiency of vitamin D.
G. Active Rickets
It is due to vitamin D deficiency and is characterized by painless epiphyseal enlargement
of growing ends of the long bones, beading of ribs, persistently open anterior fontanelle
(after 18 months of age), craniotabes (parietal or occipital bones of skull become soft,
and dent on pressure which spring back to normal shape when pressure is released)
(in children of <1 year), and muscular hypotonia. Healed rickets is characterized by
the prominence of frontal and parietal bones of skull (referred to as frontal/parietal
bossing), knock-knees (knees touching each other) /bow legs (legs becoming curved)
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Public Nutrition due to inward or outward lateral bending of lower limbs, as a result of weight bearing.
Look up Figure 4.4 in Unit 4 earliar for viewing there clinical manifestations.
Let us move on to essential fatty acid deficiency.
H. Essential fatty acid deficiency
Phrynoderma: Phrynoderma is a hyperkeratotic lesion of the skin. Projections that
resemble cones are formed surrounding the mouths of hair follicles. It is readily
recognized by the spiky feeling it gives, when the palm is passed over the affected skin.
It is generally seen on back of elbows, around knees and sides. They may sometimes
be pigmented and the surrounding skin is dry.
Let us review the clinical signs of fluorosis  a condition caused by excess intake of
fluorine.
I. Fluorosis
Earlier stages of fluorosis are characterized by changes in teeth known as dental
fluorosis. Normal teeth are ivory white in appearance. In fluorosis, the teeth are
mottled (with yellowish streaks) and appear chalky white (opaque) with brownish
patches as you may recall seeing in Figure 4.5 earlier in Unit 4. Sometimes, pitting or
chipping of enamel is seen, especially in the upper incisors. In areas of severe endemic
fluorosis, many adolescents and young adults may also have skeletal deformities
particularly in spine.
For your convenience, the various signs and symptoms of the nutrition deficiency
disorders, we have discussed above are summarised in Table 8.1.
Table 8.1: Nutritional deficiency disorders and signs and symptoms
Nutritional Deficiency Signs and Symptoms
Disorders
Kwashiorkor l Oedema
l Underweight (<80% of normal weight-for-age)
l Moon face
Marasmus l Extreme muscle wasting - “skin and bones”
l Old man’s or monkey face
Marasmic kwashiorkor l Extreme muscle wasting - “skin and bones”
l Old man’s or monkey face
l Absolute weakness
l Oedema
Vitamin A deficiency Changes in the eye such as

l Conjunctival xerosis:dryness of the transparent
membrane that covers the cornea and lines inside
of the eyelid
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l Xeropthalmia (including keratomalacia): cornea Status in Community
becomes soft and raw and easily infected Settings-II
l Bitot’s spot: dry foamy, triangular spots appearing
on the temporal side of the eye
l Night blindness: inability to see in dim light
Iron deficiency anaemia l Paleness of conjunctiva

l Paleness of tongue
l Paleness of mucosa of soft palate
l Low haemoglobin
l Swelling of feet in severe anaemia
l Spoon shaped nails
Iodine deficiency disorder l Thyroid enlargement: gland visible and enlarged
l Cretinism
Riboflavin deficiency l Angular stomatitis- lesions on both angles of the
mouth
l Glossitis- Tongue bright red or magenta
l Cheilosis- Lips become red and develop cracks
Niacin deficiency l Dermatosis- Symmetrical skin lesions evident only
on areas exposed to sunlight
Vitamin C deficiency l Spongy bleeding gums
Rickets l Changes in skeletal system- such as beading of

ribs, pigeon chest: protruding breast bone, knock-
knees or bow legs
Essential fatty acid l Lesions in the skin-generally seen on back of

deficiency elbows, around knees and sides
Fluorosis l Mottled teeth with chalky white and brownish areas

with or without erosion of enamel
We discussed above that we can assess various nutritional problems by looking at the
clinical signs in the person. We will now discuss the next method of direct nutritional
assessment which is the biochemical assessment. But first let us recapitulate what we
have learnt so far.
1. What are the other three methods of direct assessment of nutritional status in
addition to nutritional anthropometry?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
2. What do you mean by clinical assessment?
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167
Public Nutrition
3. List two clinical signs each of the following nutritional disorders.
Nutritional Disorders Clinical Signs
Kwashiorkor
Vitamin A deficiency
Anaemia
Iodine deficiency
Riboflavin deficiency
Niacin deficiency
Vitamin C deficiency
Rickets
Fluorosis
Now, let us learn about the biochemical assessment.
8.3 BIOCHEMICAL ASSESSMENT

Biochemical assessment deals with measuring the level of essential dietary
constituents (nutrient concentration, metabolites) in the body fluids (normally
blood and urine) which is helpful in evaluating the possibility of malnutrition. We
have learnt in the previous unit that in the development of nutritional deficiency disease,
certain biochemical changes occur before clinical changes take place. These are also
considered to indicate sub-clinical nutritional status with reference to various nutrients.
The range of biochemical tests that can be used is considerable. Before we go into
details about various biochemical tests, we will give you an overview of biochemical
tests. Let us begin with an overview of biochemical tests.
8.3.1 Biochemical Tests - An Overview

Before we conduct a biochemical test, there are some important points about which
we should know. These are: what is an ideal biochemical test, what criteria do we use
for selection of field test, what precautions do we use while performing a test, why
do we need accuracy and what is the importance of standardization in these tests. Let
us find out the answers to these questions next.
What is an ideal test?
An ideal biochemical test suitable for field survey should be sensitive (easily identify
most positives), specific (easily identify normal subjects), easy to carry out, preferably
non-invasive and inexpensive. It should reveal information on the extent of tissue
unsaturation rather than the fluctuations that occur with variations in the diet. However,
it is often difficult to have a biochemical test satisfying all these specified conditions.
The choice of the test depends on the actual aim i.e. to make diagnosis of population
surveys.
What is the criterion for selection of field tests?
In the field conditions, the selection of the tests will be limited by the need for single-
specimen tests rather than tests required more than once, age groups (collection of
blood samples in young children being difficult), the site of collection of blood samples
(finger-prick vs. veni-puncture samples), availability of laboratory facilities and skilled
168 manpower. Thus, for field surveys, finger-prick blood samples and random samples of
urine are more preferred. In a large-scale field survey, it is often not possible to collect Assessment of Nutritional
fasting samples of blood like for assessment of the extent of diabetes mellitus. The Status in Community
Settings-II
samples should be stable particularly during transport, not requiring refrigeration, as
far as possible, and should not be affected by the recent meal or water consumption.
In view of this, currently, tests involving dry blood spot methods are being
developed. For example, such tests are already available for estimation of haemoglobin
and serum vitamin A. It is often suggested, considering the logistic difficulties and the
cost of the tests, that biochemical assessment be carried out in a sub sample of the
study population.
What precautions do we take while performing a biochemical test?
Another important factor of consideration is use of disposable lancets for finger pricking
and of disposable syringes for venipuncture specimens to avoid the danger of hepatitis
and HIV infections. Even the investigators collecting the blood samples should wear
disposable gloves as a precautionary measure against these.
The commonly included biochemical investigations in some routine field surveys are
estimation of haemoglobin to assess the extent and distribution of anaemia and urinary
iodine estimation to assess iodine status of the communities. In specific surveys for the
assessment of sub-clinical deficiency of vitamin A deficiency, estimation of serum
vitamin A is also being attempted.
Next, let us get to know why there is a need for accuracy and standardization of
procedures in biochemical assessment.
Why there is a need for accuracy?
In the selection of methods for field surveys, accuracy and precision should not be
sacrificed for the sake of convenience. For example, in large scale national surveys
in India ‘haemocue’ was used as it was simple and required a drop of blood for
estimation of haemoglobin. Subsequent investigations have revealed that ‘haemocue’
gives higher values of haemoglobin in countries like India, where anaemia is widely
prevalent leading to underestimation of the prevalence. Thus, in the selection of methods
and equipments, appropriate care should be taken.
Why standardizing the procedures?
As discussed earlier, it is very important to standardize the procedures and the
investigators for accurate measurements. All the equipment should be tested for their
accuracy and necessary care should be taken to carry voltage stabililizers in rural
areas where electricity fluctuations are very common. The training of the investigators
should be such that the between observer and within observer variations should be
within the allowable minimum ranges. It should be recognized that errors could lead
to inaccuracy, if the procedures of collection of samples are not proper. Cold storage
of the biological specimens is most often required and adequate arrangements should
be made for the purpose. If the samples are collected elsewhere and are transported
to the laboratory, steps should be taken to provide for cold thermos flasks, which would
keep cool for sufficient length of time.
Having learnt about the basic concepts of biochemical assessments, it is now the turn
of biochemical tests i.e. let us review the different biochemical tests which can be
used to assess nutritional status.
8.3.2 Biochemical Tests for Nutritional Deficiencies

We will now discuss the different biochemical tests used to assess nutritional status
of community. It may be mentioned that the information on methodology for conducting
the various tests is not provided in this section, since it is not within the preview of
this unit. If you are interested to know about the methodology, we suggest you look
up the publications on laboratory methods of biochemical tests in any library or perhaps 169
Public Nutrition find it on the internet. Here our focus will be to learn about the different tests that could
be used to assess the sub-clinical status of various nutritional deficiencies and about the
interpretation of results. The nutritional deficiencies that we will discuss are:
A. Protein energy malnutrition,
B. Vitamin A deficiency,
C. Anaemia,
D. Iodine deficiency,
E. Vitamin D deficiency, and
F. Other nutrients like riboflavin, niacin, folic acid, vitamin B12 and zinc.
Let us start with protein energy malnutrition.
A. Protein Energy Malnutrition
In most situations, dietary protein deficiency is secondary to calorie deficiency; dietary
protein deficiency may be a specific problem only in some clinical conditions.
The principle is that in protein deficiency, proteins and its derivatives are lowered.
A number of tests like serum proteins, urea creatinine ratio and hydroxyproline
index have, therefore, been suggested to assess protein nutritional status. However,
these are not sensitive indicators of early protein malnutrition and do not provide any
additional information over anthropometry. However, in clinical practice and nutrition
surveys, serum albumin is the preferred method. Serum albumin reflects the long-term
changes in protein nutritional status. The guidelines for determining changes in protein
nutritional status of children using serum albumin as an indicator are presented in
Table 8.2.
Table 8.2: Serum albumin levels as an indicator to assess protein
nutritional status in children
S.No. Protein Nutritional Status Serum Albumin Levels (g/100 ml)
1. Deficient (high risk) < 2.8
2. Low (medium risk) 2.8-3.4
3. Acceptable (low risk) > 3.5
Serum proteins, though are used in some cases, but can be raised during infections,
which are very frequent in rural preschool children. Hence, we need to consider this
aspect while using this measure. You can note from Table 8.2 that different serum
albumin cut-off values are used to indicate deficiency (high risk), low or medium risk
and acceptable cases.
Let us go to the Vitamin A deficiency assessment tests next.
B. Vitamin A Deficiency
There are three methods to assess vitamin A deficiency. These include:
1. Serum retinol method,
2. Relative dose response method, and
3. Filter paper method.
Let us get to know them.

170
1. Serum retinol method Assessment of Nutritional
Status in Community
Serum retinol or serum vitamin A is generally the simplest and feasible method of Settings-II
assessment of vitamin A status in communities. It may be noted that this indicator does
not indicate the true tissue status of vitamin A. The guidelines for determining the
vitamin A status based on serum retinol is given in the Table 8.3.
Table 8.3: Vitamin A status based on serum Vitamin A levels
S.No. Vitamin A Status Serum Vitamin A Levels
g/dl  mol/liter
1. Deficient (high risk) < 20 < 0.7
2. Low (moderate risk) 20-30 0.7-1.05
3. Acceptable > 30 > 1.05
Vitamin A is regarded as public health problem in a community if serum vitamin A

levels are <10 g/dl or <0.37 mol/liter in more than 5% of children under the age of
six years. In other words, in such communities, there is a need for initiating nutrition
intervention programmes like vitamin A supplementation.
Let us now learn about the second method which we can use to assess vitamin A
status.
2. Relative dose response method
A new method known as Relative dose response (RDR) is considered to be a better

indicator of vitamin A stores in the body. Increase (%) in serum vitamin A levels is
measured after a small oral dose of 450-1000 g of vitamin A. The post dose is
inversely related to the vitamin A status of the individual. An increase >20% is indicative
of vitamin A deficiency in an individual. The limitation of the test is that it requires
taking blood samples twice, which may not be feasible in young children particularly
in community surveys. This limitation could be got over in Modified Relative Dose
Response (MRDR) test where only one blood sample after administration of a prescribed
dose (100 g/kg body weight) of dehydroretinol (DR) is taken.Children with DR/retinol
(R) Value of >0.06 are taken as vitamin A deficient. The major limitation of serum
retinol estimations is the requirement of sophisticated and expensive instruments like
High Pressure Liquid Chromatography (HPLC). Finally let us learn about the filter
paper method.
3. Filter paper method
In the filter paper method, a blood spot is collected on a special filter paper and dried
and carried to a laboratory for estimating serum retinol levels. This method though is
simple, requires HPLC and the samples should be kept in cold storage. These facilities
may not be available in many areas.
Next, let us learn about the biochemical assessment methods for the presence of
anaemia in individuals.
C. Anaemia
Nutritional anaemia, as you may already know, is the most widespread of all the
nutritional deficiencies. It is largely due to iron deficiency though folate deficiency is
also observed in poor communities. There are two main methods used to assess iron
deficiency. These are: 1) measurement of haemoglobin, and 2) estimation of iron
stores. Let us review these now. 171
Public Nutrition 1. Measurement of haemoglobin
Measurement of haemoglobin is the simplest method to assess nutritional anaemias in
communities. In fact in view of the subjective bias in identifying clinical anaemia,
haemoglobin estimation is adopted in large-scale surveys. It requires 20 l of finger-
prick blood sample, collected in a haemoglobin pipette and is estimated by
cyanmethaemoglobin method by colorimetry. Inexpensive models of colorimeters are
available in India now. Earlier in sub-section 8.3.1, we studied about the Haemocue
method which is also used to assess haemoglobin levels. Because haemocue is easy
to use in a field situation, it is recommended for use. However, it has few limitations
specific to accuracy, which needs to be considered.
The criteria for diagnosing anaemia as recommended by the World Health Organization
are given in Table 8.4.
Table 8.4: WHO guidelines for diagnosing anaemia
Group Cut-off for Haemoglobin (g/100 ml)
Children < 6 years 11
Children > 6 years Adolescents
Non-pregnant and non-lactating
adult women 12
Pregnant women 11
Lactating women 12
Adult males 13
Cases with values lower than the cut off suggested in Table 8.4 are considered
anaemic.
Next let us learn about methods of estimating iron stores in the body.
2. Estimation of Iron Stores
Estimation of either bone-marrow iron or serum ferritin, both of which are lowered,
indicates the earliest stage of iron deficiency. Other than serum ferritin, transferrin
saturation, erythrocyte protoporphyrin and serum transferrin receptors are the
other measures used to examine the prevalence of iron deficiency. Let us get to know
about these measures.
Serum Ferritin (SF) test permits an evaluation of the storage iron level of a population.
At all ages, serum ferritin levels <12 g are strongly suggestive of iron deficiency.
What we need to know here is that any inflammatory condition can also lead to
increase in serum ferritin levels and, therefore, should be excluded. Serum iron is also
estimated to assess iron deficiency. Serum iron levels < 40 g/dl and transferrin
saturation of <15% are suggestive of iron deficiency. Transferrin saturation helps to
determine whether the supply of iron is appropriate for the bone marrow, which is
responsible for the production of haemoglobin and red blood cells. This is a ratio
(expressed as percentage) of serum iron and total iron binding capacity. The normal
value is 33%. A low transferrin saturation and serum iron are characteristics of both
iron deficiency, and recent or concurrent infection. Erythrocyte Protoporphyrin, like,
transferrin saturation, helps to determine the supply of iron. Erythrocyte protoporphyrin
is elevated in cases of iron deficiency (i.e. when there is insufficient supply of iron for
heme synthesis). In children below the age of four, values > 80 g/dl of red blood cells
are indicative of iron deficiency. Serum transferrin receptors, is a new test for the
evaluation of iron status. Measurement of circulating transferrin receptor, on cell
surfaces and in plasma, provide a reliable index of iron deficiency anaemia. Transferrin
receptors become elevated whenever there is insufficient iron supply to cells or iron
172 depletion.
The criteria generally used to diagnose iron deficiency is listed in Table 8.5. Assessment of Nutritional
Status in Community
Settings-II
Table 8.5: Diagnostic criteria for iron deficiency anaemia
Indicator Cut-off Point
Serum Iron (µg/dl) < 60
Total iron binding capacity (µg/dl) > 300
Transferrin saturation (%) < 15
Erythrocyte protoporphyrin (µg/dl) > 100
Serum ferritin (µg/l) < 12
In view of the need for laboratory facilities and skilled man power these tests are
carried out only on a limited scale.
Next, let us go over to tests related to iodine deficiency.
D. Iodine Deficiency
Urinary iodine levels reflect the iodine status in a community. On adequate dietary
iodine intakes, the median urinary iodine is 100 g/l and is considered as normal. In
other words, in areas with adequate iodine intakes, in half of the population urinary
iodine level will be >100 g/l. Similarly, if in > 20% of the subjects, urinary iodine levels
are < 50 g/l, the population is considered to be iodine deficient. The cut-off points for
defining the iodine status of a population according to the median urinary iodine
concentration are given in Table 8.6.
Table 8.6: Criteria for defining the iodine status of a populataion based
on median urinary concentration
Iodine Status Median Urinary Iodine

Concentration (µg/dl)
Severe iodine deficicieny < 20
Moderate iodine deficiency 20 - 49
Mild iodine deficiency 50 - 99
Ideal iodine intake 100 - 200
More than adequate iodine intake
(may increase the risk of iodine induced
hyperthyroidism) 201 - 299
Excessive iodine intake > 300
Let us now discuss the biochemical tests for vitamin D deficiency.
E. Vitamin D Deficiency
Clinical forms of vitamin D deficiency are rare in community surveys and cases of
rickets are seen only in hospital practice. Serum levels of 25-hydroxy cholecalciferol
or 25 HCC (which you may recall reading in the Nutritional Biochemistry course, Unit
3, is a metabolite of vitamin D) are the accepted indicators of vitamin D deficiency.
Levels >10 ng/ml (25 nmoles/l) are considered acceptable while 5-10 ng/ml as low and
< 5 ng/ml as high risk.
Let us go over to the biochemical tests for deficiency of other nutrients. 173
Public Nutrition F. Other Nutrients
Biochemical tests related to the deficiency of other nutrients i.e. riboflavin, niacin, folic
acid, vitamin B12 and zinc can also be considered, for assessing biochemical status of
community. These are indicated in Table 8.7. These are carried out in specific surveys.
Table 8.7: Biochemical tests and criteria for nutritional deficiencies
Nutritional Deficiency Test Deficiency Criterion
Riboflavin 1. Urinary Riboflavin < 80 mg/g of Creatinine

2. Erythrocyte Glutathione >1.7 (high risk)
Reductase (EGR) test
Niacin Ratio of N’-methyl -2-

pyridone-5 carboxylamide
and NI-methylnicotinamide <1
Folic acid Serum Folate < 3ng/ml

RBC Folate 140 ng/ml
Vitamin B12 Serum B12 80 pg/ml
Zinc Plasma Zinc < 84g/dl
Interpretation of biochemical parameters is often complicated. It is not frequent to

observe florid cases of clinical nutritional deficiencies with normal biochemical values
at the community level. Other factors like dietary intakes and bioavailability of nutrients
should be considered for proper interpretation of the biochemical values. A common
example is Total Goitre Rate (TGR) and urinary iodine levels, despite the TGR being
in the endemic range, the median urinary iodine values are normal. In such cases, the
distribution of biochemical values would be better.
We hope having gone through the discussion above, you would now be in a good
position to identify the biochemical tests which you would use while conducting nutritional
assessment of population groups. Let us take a break here and then answer the
questions given in check your progress exercise 2.

1. What do you understand by biochemical assessment? What are the
characteristics of an ideal biochemical test?
..........................................................................................................................
..........................................................................................................................
2. Match the following biochemical tests in column A with the nutritional deficiencies
in column B.
Column A Column B
1. Serum albumin a. Goitre
2. Serum retinol b. Anaemia
3. Haemoglobin c. PEM
4. Urinary iodine d. Vitamin A
5. Serum folate e. Riboflavin
6. Erythrocyte glutathione f. Folic acid
reductase
174
3. What are the methods to assess: Status in Community
Settings-II
a. Vitamin A deficiency
.................................................................................................................
.................................................................................................................
.................................................................................................................
b. Iodine deficiency
.................................................................................................................
.................................................................................................................
.................................................................................................................
We have learnt about the clinical assessment and biochemical assessment as methods
of direct nutritional assessment. Let us now study about the last method i.e. dietary
assessment of nutritional status.
8.4 DIETARY ASSESSMENT

Dietary assessment is conducted with the help of diet surveys. When a systematic
inquiry into the food supplies and food consumption of individuals and population
groups is made, we call it a diet survey. Diet surveys, most often are a part and
parcel of routine nutrition surveys. Accurate information on dietary patterns of
communities would help in assessing the nutritional status of people but also for
determining the relationship between nutrient intakes and deficiency diseases. These
would help in understanding the dietary status of the community vis-à-vis other indicators
of nutritional status like anthropometry, clinical signs of deficiency or biochemical
parameters. Sometimes, dietary assessment of subjects in an institution like hostels or
prisons also may be required to assess the adequacy of diet for any modifications. An
appraisal of the dietary adequacy for populations would be required for planning
programmes to overcome diet related disorders and to promote nutrition in general.
Quantitative data on dietary intakes of populations are taken into consideration for
fixing minimum wages and rations for households. In the recent past, assessment of
the extent of poverty is based on dietary energy consumption pattern.
The dietary intakes can be assessed quantitatively either at the family or individual
level. Sometimes institutional diet surveys are also important to find out the dietary
intakes of individuals in large institutions. We would now study about common methods
to assess dietary intakes at various levels.
The commonly used methods are:
l Family/Household Diet Survey
a. Weighment method
b. Consumption Expenditure Survey
l Assessment of dietary intakes of individuals
a. Individual Oral Questionnaire (24 hour recall method),
b. Food Record or Diary and
c. Diet History.
175
Public Nutrition l Qualitative Survey
l Institutional Diet Survey
l Food Balance Sheets
Let us begin with dietary surveys for the family.
8.4.1 Family Diet Surveys
Family diet surveys collect information on diet at the household level. The results are
expressed as per capita or per consumption unit. In these surveys, it is not possible to
find out the intakes of particular age groups or physiological groups. Since these are
simpler than 24-hour recall individual diet surveys about which he will study later in this
Unit, routine nutrition surveys adopt these methods. These methods include: weighment
method and consumption expenditure surveys.
Let us learn about these methods in details. Let us begin with Weighment method first.
A. Weighment Method
Weighment method of diet survey involves actual weighing of raw foods on a given
day. The investigator visits the households before the food is cooked and weighs with
the help of a grocer’s balance or on a electronic balance all the foodstuffs (edible
portions) that will be cooked for the day.
Earlier, weighment of foods was being carried out on seven consecutive days and the
method was known as seven-day weighment method. Seven day surveys were
logistically more difficult and time consuming. They also required complete cooperation
of the households selected for the purpose. In the nineteen sixties, considering the
monotony of the rural Indian diets with hardly any variation in the diet, after comparing
the results of seven day and one day methods, it was decided to adopt one-day
weighment diet surveys for assessing family dietary status in villages. Even now, in the
urban areas, 3-day weighment is adopted, since there is more variation in these diets.
Under weighment method, all the raw food items (edible) are weighed according to
meal pattern (i.e. breakfast, lunch, evening tea and dinner) for the day of survey using
grocer’s balance and local measures. Information on all the family members who will
be consuming the meal on that day is collected according to age and physiological
status. In the case of young children, information on breastfeeding and complementary
feeding practices is also collected. The respondent (house wife) is requested to bring
all the raw foodstuffs she will be using for that day’s menu. Each food item is weighed
carefully and the weights are recorded in a proforma. The team is expected to visit
the house as many times as the food is cooked and weigh all the foods that will go
into the meal. However, in practical terms, often this may not be possible as the family
may have foods just adequate for one meal and for the evening meal foods may be
purchased only after the day’s wages are collected. Therefore, information about what
the quantities of foods would be, is collected from the respondent. It is also important
to collect information about foods eaten outside home, supplementary food given to
young children and food that is left over at the end of the day. In certain areas, even
the cattle are fed either chapatis (roties) or rice. This information should be collected
properly so that there will be overestimation of the intakes. As far as possible, the survey
should not be carried out either on feasts or fasting days. Similarly, on occasions when
special guests are present, the diet may not represent the actual intakes in the family.
In the urban areas, the data is collected in the same way for three consecutive days.
The dietary consumption is usually expressed per consumption unit (CU), which
represents the intake of a sedentary adult male. These consumption units are calculated
based on the calorie coefficients suggested based on the calorie requirements for
different age, sex and physiological groups. The calorie requirements for one consumption
unit are 2400 kcals. The Indian Council of Medical Research (ICMR) recommends
the following calorie coefficients as given in Table 8.8, considering the value for a
176 sedentary adult male as 1.
Table 8.8: Calorie coefficient expressed in relation to consumption units Assessment of Nutritional
(CU) for age/sex/activity levels Status in Community
Settings-II
Age/ sex/physiological group CU
Adult Male – sedentary 1
Adult Male – moderate activity 1.2
Adult Male – heavy activity 1.6
Adult Female – sedentary 0.8
Adult Female – moderate activity 0.9
Adult Female – heavy activity 1.2
Adolescents (12-21 years) 1.0
Children – 9-12 years 0.8
The total number of consumption units in each family is first calculated based on
the information on age, sex, activity, and physiological status of all the individuals in
the family. The number of consumption units will be less than the total number of
members in the family. We can calculate intake of each food per consumption unit as
follows.
Raw amounts of each food
Intake of each food/ CU per day =
No. of consumption units
We can explain this with the help of an example. Suppose we have a family of four
consisting of two adults and two children in a household, we can calculate the total
consumption units as shown in Table 8.9.
Table 8.9: Calculation of total consumption units by a family of four people
Characteristics Adult Male Adult Female Child (3 yrs) Child (7 yrs)
Family composition 1 1 1 1
Type of activity Moderate Moderate - -
Physiological status - (Non pregnant, - -
non lactating)
Equivalent consumption 1.2 0.9 0.4 0.6
unit (C.U.)
We can note from the Table 8.9 that total CUs for this family are 3.1. We can now
take the example of rice being consumed by the family and can calculate the intake
of rice/CU per day as follows. Suppose during the survey of this family, if the total
intake of rice is found to be 400 g/day, then intake of rice/CU/day = Total intake of
rice/total CU= 400/3.1 = 129 g. In this way, we can determine the intake of each food/
CU/day for each food consumed by the family.
177
Public Nutrition The raw foods are converted into nutrients using the food composition tables (Nutritive
Value of Indian Foods, National Institute of Nutrition, 2004), which provide nutrient
content of commonly consumed Indian foods. These are then compared with the
recommended dietary intakes suggested by Indian Council of Medical Research (ICMR)
for different nutrients for sedentary adult male to find out the adequacy or otherwise
of the diets in the family. The data obtained on all the families is then summed up to
calculate the average intakes of the community surveyed. The major limitation in the
method is that consumption units are computed on the assumption that calorie coefficients
hold good for all the nutrients. Sometimes, the data are also expressed per capita (per
head) by dividing the total consumption of foods by the total number of members
(every member is treated as equal irrespective of age/sex/physiological status) who
have partaken in the meal.
Having gone through the discussion above, you must have understood the weighment
method and per consumption unit concept. Next, we move on to the consumption
expenditure survey.
B. Consumption Expenditure Survey
In the consumption expenditure survey, the money spent on all the food and non-food
items for a fixed period in the immediate past (usually one month) is found out by
administering a specially designed proforma. This is considered to be comparable to the
results of weighment diet survey. The National Sample Survey Organization collects
such information every five years. In fact, the extent of poverty in the country is
calculated based on the results of food consumption surveys. The results provide
information on foods bought by the family, which need not always mean actual
consumption.
Having studied about the family diet surveys, next, we move on to the assessment of
dietary intakes for individuals.
8.4.2 Individual Diet Surveys

Dietary status of individual “at risk” groups is often required to plan specific programmes
for that group. For example, information of actual intakes of preschool children or
pregnant women who are considered more vulnerable is essential to assess the actual
deficit in the diets and to decide the quantities of supplements to be provided in the
intervention programmes. We will discuss three types of methods used to collect
information on dietary intakes of individuals. These are:
a. Individual Oral Questionnaire (24-hour recall method),
b. Food Record or Diary, and
c. Diet History.
Out of these, the 24 hour recall method is probably the mostly widely used method
of dietary assessment. We will now discuss these methods in details. Let us begin with
the 24 hour recall method.
a. Individual Oral Questionnaire (24-hour Recall Diet Survey)
The 24 hour recall method is used in large nutritional surveys to collect dietary intake
data of individuals. In this method, the individual is asked to recall in as much detail
as possible the food intake for the past 24 hours by interview or by completing a
questionnaire. The respondent recalls what was eaten, how much food was eaten,
how was the food prepared, when was it eaten and other details related to food
intake. However, while conducting the survey, both the respondent and the housewife
(or the person who cooks the food for the whole family) is contacted. The dietary
intakes are assessed in terms of cooked food with the help of standardized cups
178 measures appropriate for the local conditions. These cups are used to help the
respondent to easily recall the quantities of food consumed by each member. These Assessment of Nutritional
cups (generally about 12 with a teaspoon and a tablespoon) are first standardized in Status in Community
Settings-II
terms of volumes. These are so selected to represent the sizes of vessels used in the
household. The respondent is questioned about the preparations made for each meal
starting from the morning tea. For each preparation (say vegetable curry), all the
ingredients (i.e. individual vegetables, oil, spices, salt etc) used are first listed. The
housewife is then asked to give the actual weights of each of the food ingredient used
in each preparation. This will give the quantities of total raw food used for the family.
She is later asked to indicate in terms of the standardized cups the total volume of
each preparation after cooking. This would give the total cooked quantities for each
food item. For example, the volume of cooked rice may be 2-3 times of the raw
amount depending on the age of the rice. Then the respondent is asked the amounts
of cooked food consumed by each individual in the family who has partaken the meal.
This would provide the individual intake of cooked food. This is repeated for each meal
for each preparation. To check the accuracy of the assessment of the volumes by the
housewife, it would be always better to take same volume of water to assess the total
cooked quantity in the vessel used by her. This is then measured in terms of the
standardized cups. Some times, previous day’s remaining food may be consumed in the
morning. Information about the total raw, cooked amounts may be assessed as described
earlier and the individual consumption is assessed. The guidelines for conducting a diet
survey using a 24-hour recall method are attached in Annexure 1A. A schedule for
24-hour recall method is attached at Annexure 1B at the end of the course material.
Well, there are certain points to remember while doing the 24-hour recall. What are
they? Let us find out.
We should remember that while doing a 24-hour recall, each and every ingredient used
in the preparation of meals should be included. In the case of milk/curds/buttermilk,
the extent to which these were diluted should be found out, as it is a common practice
in rural families. In the case of bread, the number of slices per loaf should be assessed
so as to approximately assess the weight of each slice. In the case of rotis or
pancakes, the number should be recorded. A thorough knowledge of the local measures,
the preparations, and the method of preparation is essential for obtaining valid results.
Thus, for the purpose of calculation, the important step is to convert the individual
cooked intakes into raw amounts of each food item as shown in the formula herewith.
Total raw amount for each food item (g)  Individual cooked intake (vol.)
Individual Raw Intake =
Total cooked amount of the preparation (vol)
This calculation is repeated for each and every food item that was used in the meal
and the total amounts consumed by each individual of each food item are computed.
From the raw amounts, the nutritive value of each food item is calculated using the
food tables as indicated earlier. It is often recommended that the information may be
collected on all the members of the family even if the information is required for a
particular group. The advantages are that this provides an opportunity to find out the
intra-family distribution of diet and to assess whether a particular group is at a more
disadvantage. Literature reveals that in India the dietary distribution is unfavourable to
preschool children in the sense that even if other members in that family meet the
requirement of nutrients like energy, a significant percentage of preschool children are
given inadequate energy diets.
The 24-hour recall has several strengths. It is inexpensive and quick to administer
(20 minutes or less) and can provide detailed information on specific foods. It requires
only short term memory. It is well accepted by respondents because they are not
asked to keep a diet records and their expenditure of time and efforts is relatively
low. The method also has several limitations. Individuals may withhold or alter information
about what they ate due to poor memory or embarrassment or to please or impress
the interviewer and researchers. Also, data on a single day’s diet, no matter how 179
Public Nutrition accurate, are a very poor descriptor of an individual’s usual nutrient intake because of
day-to-day or intra individual variability. However, a sufficiently large number of 24
hour recalls may provide a reasonable estimate of the mean nutrient intake of a group.
Let us now move on to the next method of assessing individual dietary intake i.e. Food
Record or Diary.
b. Food Record or Diary

Food record or diary method provides food consumption data of individuals. Under this
method, the subject records, at the time of consumption, the type and amounts of all
foods and drinks consumed for a period of time usually ranging from 1 to 7 days.
Portion sizes are estimated using food models and standard measuring instruments or
food items are actually weighed. The strengths of the food record method are that it
does not depend much on memory because the subject records food and drink consumption
at the time of eating. In addition, it can provide detailed food intake data and important
information about eating habits (for example, when, where, and with whom meals are
eaten). However, the main limitation of this method is that recording food intake
requires a literate and cooperative subject who is willing to spend the time and effort.
Individuals having the time, interest and ability to complete several days of food records
without assistance may not be representative of the general population.
Let us now move on to the third method of assessing dietary intake of individuals i.e.
diet history.
c. Diet History
Diet history yields a retrospective estimate of food and nutrient intake of an individual
over a period of time. The period covered may range from a month to one year at the
most. Traditionally, the diet history approach has been associated with the method of
assessing usual diet developed by a scientist, B.S. Burke. Burke’s original method
involves four steps; 1) collect general information about the subject’s health habits
2) conduct 24-hour recall to get information on the subject’s usual pattern of eating,
3) perform a cross check on the data given in step 2, and 4) have the subject complete
a 3 day record.
Let us review these steps briefly.
1. Collect general information about the subject’s health habits: Information is collected
from the individual about the number of meals eaten per day, appetite, food
dislikes, the presence or absence of nausea and vomiting, use of nutritional
supplements, habits related to sleep, rest and work etc. This allows the interviewer
to become acquainted with the subject in ways that may be helpful in obtaining
further information.
Next, collect 24-hour recall to get information on the subjects usual pattern of
eating. Let us see how.
2. Conduct 24-hour recall to get information on the subject’s usual pattern of eating:
A 24-hour recall is conducted with the subject using the technique as discussed
earlier. The information is thus collected on subject’s usual pattern of eating during
and between the meals including types of food eaten, serving sizes, frequency and
timings. Next perform a cross check on this data as explained next.
3. Perform a cross check on the data given in step 2 above: Once the information
on 24 hour recall is collected, the data is then cross checked by asking specific
questions about the subjects’ dietary preferences and habits. For example, the
subject may have said that he or she drinks 200 ml of milk every morning. The
interviewer should then inquire about a subject’s milk drinking habits to clarify and
verify the information given about the subject’s milk intake.
180
4) Have the subject complete a 3 day record: Finally the subject is asked to Assessment of Nutritional
complete a 3-day record, which serves as an additional means of checking the Status in Community
Settings-II
usual intake.
As we said earlier, this is an approach suggested by B.S. Burke, but several investigators
have modified it to suit their needs. The strengths of the diet history approach are that
it assesses the subject’s usual dietary intake, including the seasonal variations, and
therefore, data on all nutrients can be obtained. The main limitation of this method is
that it requires 1-2 hours to conduct the interview. Highly trained interviewers are
needed and nutrient intakes tend to be overestimated.
Thus, the three methods discussed above provide information on nutrient intakes of
individuals. We can choose any method depending upon the objectives of our study,
time and resources at hand although the 24-hour recall method remains a method of
choice for large scale nutritional surveys.
The methods discussed above provide quantitative information about the diet. Sometimes
we may want to collect only qualitative information about the diet. Let us get to know
about qualitative diet surveys.
8.4.3 Qualitative Diet Surveys

In certain instances, quantitative information on dietary intakes may not be required.
Under such circumstances, qualitative data is compiled by carrying out surveys either
at family or individual level. In such surveys, information is compiled on the kinds of
foods eaten, the frequency of their consumption, perceptions of the community about
foods, attitudes towards different types of foods and the special foods consumed during
particular conditions like pregnancy or lactation. An attempt is also made to collect data
on the foods avoided during health and disease and foods restricted during morbidities.
This data is useful for planning and evaluation of nutrition education programmes. Such
data is collected through specially designed proforma.
We can study about one of such method in detail. This is known as food frequency
method.
Food Frequency Method: Food frequency method consists of asking individuals ( by

interview or checklist) how often ( daily, monthly, weekly) specific foods are eaten.
This is then used as an index of diet pattern of population groups. The underlying
principle of food frequency method is that average long term diet, for example, intake
over weeks, months or years, is the conceptually important exposure rather than intake
on a few specific days. Therefore, it may be advantageous to sacrifice precise intake
measurements obtainable on one or a few days in exchange for more crude information
relating to an extended period of time. In fact, food frequency methods has become
the primary method for measuring dietary intake in epidemiological studies as they are
easy for subjects to complete, often as self-administered form. A food frequency
questionnaire or checklist consists of two components: a food list and a frequency
response section for subjects to report how often each food was eaten. Refer to
Annexure 2 given at the end of this course. A food frequency questionnaire is given
for you reference The questionnaire consiste of a list of approximately 100 or fewer
individual foods or food groups that are important contributors to the population’s intake
of energy and nutrients. Usually, the foods are grouped into categories (based on
similarity of nutritive value, functions in the diet etc.). The strengths of food frequency
questionnaire are that they are relatively inexpensive and quick to administer in large
scale surveys. They are also considered one of the methods of choice for research on
diet-disease relationships on both the macronutrient and micronutrient levels. The key
limitation of food frequency questionnaire is that since the food list is limited to 100 or
fewer foods and food groups, these must be representative of the most common foods
consumed by individuals in a sample.
181
Public Nutrition Sometimes we would like to know the dietary intake of large groups of people consuming
food in an institution. For this, we use an institutional diet survey. Let us get to know
about them.
8.4.4 Institutional Diet Survey

Institutional diet survey is used to find out the dietary pattern of people residing in
hostels, orphanages, prisons, army barracks and homes for the aged, homogenous
groups of people take their food from a common kitchen. The method of diet
survey also is referred to as inventory method. The amounts of foods issued everyday
as per the records are collected along with information on the number of individuals
partaking in the meal. It is recommended that the inventory should be obtained for a
period of at least one week. The average intake per person per day can be calculated
as follows:
Average intake/person/day =
Stocks at the beginning of the week – Stocks at the end of the week
Total number of inmates  Number of days of survey
The major limitations of this method are that the validity of the data depends on the
accuracy of the records and any lapses in recording the issues could vitiate the results.
The selection of the reference period should be random so as to avoid any manipulation
of the records by the wardens. On a regular basis, we require information on dietary
consumption of people at a country/regional level. For this, we use food balance
sheet. Let us review what it is, next.
8.4.5 Food Balance Sheets (FBS)
The food balance sheet is a method of indirectly estimating the amounts of food
consumed by a country’s population at a certain time. It provides data on food
availability or disappearance rather than actual consumption. Food and Agriculture
Organization (FAO) of the United Nations compiles food balance sheets for different
countries. These are prepared based on the assessment of the quantities of total food
produced in the region/country, imports (if any), foods allocated for seed and industrial
purpose, animal foods and wastage of foods (if any). The amounts are divided by the
mid year population of the region/country and 365 to derive average per capita
consumption per day. Food balance sheets generally provide information as to the foods
available at the country level. The strength of this method is that it can give a total view
of the food supplies of a country and can be used in drawing conclusions about food
habits and dietary trends within a country. Food Balance Sheets are valuable for
planning international nutrition policy and formulating food programmes. They are also
useful for the administrators to monitor food position in the country. Food balance
sheets also have some limitations. The accuracy of data is dependent upon available
statistics, the quality of which can vary greatly depending upon a country’s level of
development. The data only represents the total amount of food reportedly available for
consumption, not what was actually consumed, nor does it show how food was distributed
among individuals or groups. Hence, they are of little use at the community level.
Thus, you saw that there are different methods of assessment of dietary intake at
various levels. The selection of the method of diet surveys depends upon the purpose,
the group to be studied and the resources available.
With this, we end our study on dietary assessment. In the next unit, we will study about
nutrition monitoring and surveillance.

1. Enumerate the common methods used to assess dietary intakes.
...........................................................................................................................
...........................................................................................................................
182
2. Answer these briefly: Status in Community
Settings-II
a. Strengths and limitations of 24-hour recall.
..................................................................................................................
..................................................................................................................
b. Strengths and limitations of food frequency questionnaire.
..................................................................................................................
..................................................................................................................
a. The results of family diet survey are expressed as ————————
unit.
b. The National Sample Survey Organization collects information related to
consumer ———— on food every five years.
c. The most common method to assess dietary intakes of individuals is —
———
d. —————— diet survey is used to assess dietary pattern of group of
people living in an institution.
e. Food balance sheets are useful to ————— the food position in the
country.
8.5 LET US SUM UP

In this unit, we studied about the clinical assessment, biochemical assessment and
dietary assessment, other than nutritional anthropometry, as the methods of direct
nutritional assessment. We briefly reviewed the clinical signs of common nutrient
deficiency disorders. For doing a biochemical test, we should have a knowledge of an
ideal biochemical test, criteria to be used for selection of field test, precautions for
doing the tests and importance of standardization of tests. We also learnt about the
common methods used in dietary assessment. These are Family/Household survey
which include Weighment diet survey and Consumption Expenditure survey; Individuals
dietary assessment through 24 hour recall method, Diet record and Diet history;
Qualitative survey; Institutional diet survey and Food Balance Sheets. We also learned
that only trained people should carry out clinical, biochemical and dietary assessment.
8.6 GLOSSARY
Endemic : a disease that is constantly present to a greater or lesser
degree in people of a certain class or in people living in a
particular location.
Fontanelle : the soft spots on a baby’s head where the bones of the
skull have not fused together.
Hyperkeratotic lesion : a lesion formed from excess production of keratin in the
skin.
Lancet : a surgical knife with a short, wide, pointed double-edged
blade, used especially for making punctures and small
incisions.
Sensitivity of a test : it is defined as the ability of a test to identify correctly all
those who have the disease, that is “true positive”.
Specificity of a test : it is defined as the ability of a test to identify correctly all
those who do not have the disease, that is “true negatives”.
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Public Nutrition
EXCERCISES
1. The other three methods of direct nutritional assessment in addition to nutritional
anthropometry are clinical assessment, biochemical tests and dietary assessment.
2. Clinical assessment refers to looking for changes in the body e.g. eyes, hair, skin
etc. and indicate nutritional deficiency.
3. The clinical signs of nutritional disorders :
Nutritional Disorders Signs and Symptoms
Kwashiorkor l Oedema
l Underweight (<80% of normal weight for age)
l Moon face
Vitamin A deficiency Changes in the eye such as
l Conjunctival xerosis: dryness of the transparent
membrane that covers the cornea and lines inside
of the eyelid
l Xeropthalmia (including keratomalacia): cornea
becomes soft and raw and easily infected
l Bitot’s spot: dry foamy, triangular spots appearing
on the temporal side of the eye
l Nightblindness: inability to see in dim light
Iron deficiency anaemia l Paleness of conjunctiva,
l Paleness of tongue
l Paleness of mucosa of soft palate
l Swelling of feet in severe anaemia
l Spoon shaped nails
Iodine deficiency disorder l Thyroid enlargement: gland visible and enlarged
l Cretinism
Riboflavin deficiency l Angular stomatitis- lesions on both angles of the
mouth
l Glossitis- Tongue bright red or magenta
l Cheilosis- Lips become red and develop cracks
Niacin deficiency l Dermatosis- Symmetrical skin lesions evident only
on areas exposed to sunlight
Vitamin C deficiency l Spongy bleeding gums
Rickets l Changes in skeletal system- such as beading of
ribs, pigeon chest: protruding breast bone, knock-
knees or bow legs
Fluorosis l Mottled teeth with chalky white and brownish
184 areas with or without erosion of enamel
Check Your Progress Exercise 2 Assessment of Nutritional
Status in Community
1. Biochemical assessment deals with measuring the level of essential dietary Settings-II
constituents (nutrient concentration, metabolites) in the body fluids ( blood and
urine normally) which is helpful in evaluating the possibility of malnutrition. An
ideal biochemical test suitable for field survey should be sensitive (easily identify
most positives), specific, easy to carry out, preferably non invasive and inexpensive.
2. 1-c; 2-d; 3-b; 4-a; 5-f; 6-e
3. a. There are three methods to assess vitamin A deficiency. These include:
i. Serum retinol method
ii. Relative dose response method and
iii. Filter paper method
i. In serum retinol method, vitamin A is regarded as public health problem in a
community if serum vitamin A levels are <10 g/dl or <0.37 mol/liter in more
than 5% of children under the age of six years.
ii. In the relative response method, increase (%) in serum vitamin A levels is measured
after a small oral dose of 450-1000 g of vitamin A. The post dose is inversely
related to the vitamin A status of the individual. An increase >20% is indicative
of vitamin A deficiency in an individual.
ii. In the filter paper method, a blood spot is collected on a special filter paper and
dried and carried to a laboratory for estimating serum retinol levels.
b. Iodine deficiency is assessed by urinary iodine levels as these reflect the
iodine status in a community. On adequate dietary iodine intakes, the median
urinary iodine is 100 gl is considered as normal. In other words, in areas
with adequate iodine intakes, in a half of the population urinary iodine level
will be >100 g/l. Similarly, if in >20% of the subjects, urinary iodine levels
are < 50 g/l the population is considered to be iodine deficient.
1. The common methods used in dietary assessment are:
a. Family/Household diet survey i.e. Weighment method and Consumption
expenditure survey
b. Assessment of dietary intake of individuals i.e. 24 hour recall method Diet
record and Diet history method
c. Qualitative survey
d. Institutional diet survey, and
e. Food Balance Sheets
2. a. Strengths and limitations of 24 hour recall: The strengths of 24 hour recall
methods are that it is inexpensive and quick to administer ( 20 minutes or
less) and can provide detailed information on specific foods. It requires only
short term memory. It is well accepted by respondents because they are not
asked to keep diet records and their expenditure of time and efforts is
relatively low. The limitations include: Individuals may withhold or alter
information about what they ate due to poor memory or embarrassment or
to please or impress the interviewer and researchers. Data on a single day’s
diet, are a very poor descriptor of an individual’s usual nutrient intake because
of day-to-day or intra individual variability.
185
Public Nutrition b. Strengths and limitations of food frequency method: The strengths of food
frequency questionnaire are that they are relatively inexpensive and quick to
administer in large scale surveys. They are also considered one of the
methods of choice for research on diet-disease relationships on both the
macronutrient and micronutrient levels. The key limitation of food frequency
questionnaire is that since the food list is limited to 100 or fewer foods and
food groups, these must be representative of the most common foods consumed
by individuals in a sample.
3. a. consumption
b. expenditure
c. 24 hour recall
d. Institutional
e. monitor
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Nutrition Monitoring
UNIT 9 NUTRITION MONITORING AND and Nutrition
Surveillance
NUTRITION SURVEILLANCE
Structure
9.1 Introduction
9.2 Nutrition Monitoring
9.2.1 Objectives and Components of Nutrition Monitoring
9.2.2 Current Programmes of Nutrition Monitoring in India
9.3 Nutrition Surveillance System (NSS)

9.3.1 Objectives of Nutrition Surveillance
9.3.2 Uses of Nutrition Surveillance System
9.3.3 Infrastructure for Nutrition Surveillance System
9.3.4 Key indicators of Successful Nutrition Surveillance Programme
9.3.5 Computerization for Monitoring and Surveillance
9.4 Let Us Sum Up

9.5 Glossary
9.1 INTRODUCTION
In the previous Units 7 and 8, we learnt about different methods of assessment of
nutritional status of communities. Now we would like to know whether the nutritional
status of community is improving or not and, if not, then what actions could be taken
to improve the nutritional status. For this purpose, we use the processes of nutrition
monitoring and nutritional surveillance.
We have learnt in the previous units that, in direct assessment of nutritional status,
nutrition surveys are used to collect information on population. Most often, the nutrition
surveys are conducted not only at one point of time to understand the current status
of a given community, but also are repeated periodically to find out the changes that
may occur over time. The Union and State Governments in India have been investing
large sums of money on several direct and indirect interventions to improve the overall
health and nutrition of vulnerable groups of population. We will learn about these
interventions later in Unit 10. It is essential to know whether there has been any
change in the nutritional status as a result of these interventions or not; if not, then
appropriate corrective steps could be introduced, where necessary. Nutrition
monitoring is one of the tools adopted for the purpose.
During our day-to-day life, we hear regularly about the disease surveillance (cholera,
encephalitis etc.) by the health authorities. The health administration maintains a constant
vigil on occurrence of certain notifiable diseases so that they can initiate prompt control
measures to prevent the spread of these infectious diseases. This process is called
disease surveillance. In the case of nutrition, early diagnosis of malnutrition in “at
risk” population groups is crucial to institute immediate corrective action to prevent
undernutrition. More importantly, this would also help in the promotion of optimal
nutrition. Hence, effective nutrition surveillance system is required to achieve this.
In this unit, you will now learn about nutrition monitoring and surveillance and the
various mechanisms in place in the country. What is nutrition monitoring and surveillance?
What is the aim of nutrition monitoring? How is nutrition monitoring and surveillance
carried out at the community level? These are a few issues discussed in this unit. 187
Public Nutrition Objectives
l describe the concept of nutrition monitoring and nutrition surveillance;
l enumerate the aim of nutrition monitoring and surveillance and the basic principles;
l explain the various programmes through which these activites are being carried
out in India; and
l organize activities related to nutrition monitoring and surveillance at community
level.
9.2 NUTRITION MONITORING

The terms ‘monitoring’ and ‘surveillance’ are often used as synonyms in nutrition
assessment. However, it is important to understand the difference between these two
terms. Let us begin by understanding what we mean by monitoring. Monitoring
literally means ‘to supervise’ or ‘to keep an eye on’ or ‘to scrutinize’. ‘Monitoring
refers to the collection, analysis and feedback quantitatively precise measures
from a relatively large representative sample of a population – at the National
and State levels – essentially for the purposes of tracking time trends and
understanding population sub-group differences in diet, nutritional status and
nutrition-related health and disease risks.
You may be aware that the governments provide for built-in monitoring systems in
most of the programmes that are implemented by them particularly with respect to the
inputs either in terms of money or material. On the other hand, the aim of any
monitoring should be to assess whether the goals (with respect to the outcomes), set
at the beginning of launching such interventions have been met. Therefore, nutrition
monitoring is a tool to keep a watch on the nutritional status of communities to
assess the changes in nutritional status of communities over a period of time.
WHO defines nutrition monitoring as the “measurement of changes over time in the
nutritional status of a population or a specific group of individuals”. Thus,
nutrition monitoring involves repeated measurements on a representative population.
You would also realize that quite often, the terms of monitoring and evaluation are
used together. Evaluation is, in fact, a detailed appraisal of an intervention programme
by examining the processes of implementation (pertaining to delivery inputs like
outreach of the programme etc.) and the outcome variables (e.g. nutritional
status) to determine as to how far the programme goals have been achieved and
if not, then reasons for non achievement of goals.
Let us now learn about the objectives and components of nutrition monitoring.
9.2.1 Objectives and Components of Nutrition Monitoring
In the section above, we learnt that nutrition monitoring is a means to keep a watch
on the nutritional status of communities. In fact, the objectives of nutrition monitoring
are two fold. These are enumerated herewith:
Objectives of nutrition monitoring
The objectives include:
1. to assess the nutritional status of representative groups of communities on a
continuous basis in order to study the changes in the nutritional status, if any, and
2. to evaluate the various nutrition intervention programmes in operation to determine
the achievement or otherwise of the goals.
In fact, a well-planned and integrated national nutrition monitoring system should cover
188 the following content areas:
l food and nutrient consumption at household and individual levels, Nutrition Monitoring
and Nutrition
l nutritional status by anthropometry and clinical nutritional deficiency conditions, Surveillance
l nutrition-related risks of selected chronic diseases,

l food security, particularly at the household level,
l the above information focused on selected high risk sub-population groups like
Below Poverty Line (BPL) population, population in chronically drought prone
area and tribal populations,
l identification of vulnerable sub-groups of the population at higher risk of nutrition-
related health problems,
l food supply- agricultural and horticultural, and
l food safety.
You should know that it requires at least a year to demonstrate changes in nutritional
status at the community level, so the periodicity of nutrition monitoring is usually once
a year. In India, five year monitoring is also suggested to coincide with the Five Year
Plans.
The objectives of nutrition monitoring, the target groups to be monitored and the
availability of resources determine the components of nutrition monitoring. In countries
like India, where clinical malnutrition is still widely prevalent, monitoring of both clinical
(for example, assessment of clinical signs in case of kwashiorkor/marasmus,
xeropthalmia and goitre etc.) and of sub-clinical nutritional status (anthropometric and
biochemical indicators) would be required. However, with improvement in the nutritional
status of communities, the emphasis can be shifted to sub-clinical forms. The nutritional
monitoring data could also be used in the revision of the dietary guidelines for Indians
at regular intervals of about 10 years.
Next, what are the components of nutritional monitoring? Let’s find out.
Components of nutritional monitoring
Let us look at the two main components of nutrition monitoring. These are:
1. population groups, and
2. key indicators used in monitoring.
We shall start with the population groups.
1. Population for Monitoring
For nutrition monitoring, it is necessary to decide the groups of population, especially
those, at risk of developing malnutrition. Considering the current status of nutrition of
different groups, monitoring of nutritional status of mothers and children should receive
utmost priority. Since the nutritional status of preschool children is accepted to reflect
the nutrition of a community, under conditions of resource constraints, it may be
adequate to collect data on this age group only. However, the aim should be to monitor
the whole population.
Next, let us look at the second component i.e. key indicators.
2. Key Indicators
An effective nutrition monitoring system should be able to provide information on
prevalence of nutrition disorders either by direct measurement and observation or by
self-reported disease prevalence in different groups, personal attributes, nutrition
behaviours and information on utilization of health and nutrition services. It is
recommended that as far as possible, information which indicates various aspects of
nutritional status e.g. underweight, wasting and stunting in addition to clinical assessment
189
Public Nutrition should be included. Since anaemia is a major problem among all the groups of population,
particularly among pregnant women and young children, laboratory supported haemoglobin
estimations at least once in five years may also be included. Dietary consumption by
all the individuals would provide also information on the intra-family distribution of
intakes within a family. In addition, data on various aspects of implementation of
intervention programme participation of the beneficiaries would help in linking the
nutritional status and the intervention programmes. Such data would help in assessing
the current status of the programmes and in introducing appropriate changes required.
The data so collected should be accurate and be representative of the communities.
Having studied about the indicators of nutrition monitoring, it is also important for us
to know that only standard methods should be used to conduct nutrition monitoring.
Emphasis should be placed on obtaining accurate data using sensitive indices by trained
investigators. They should use standardized equipments to indicate the nutritional status
of communities, with reasonable certainty.
Let us now learn about the current monitoring programmes in India.
9.2.2 Current Programmes of Nutrition Monitoring in India
The assessment of nutritional status of different segments of the population, particularly
in relation to dietary intakes, has been one of the important activities of nutrition
research in India for more than six decades. These have been mostly isolated studies,
either of specific groups or in specific regions of the country and they rarely assumed
an all-India character. However, with an increasing emphasis on planned development
through five-year plans, a number of organizations and departments have geared their
activities to meet the stringent needs of the planning process at national and regional
levels. These organizations provide a more systematic approach in collection and
compilation of data. The major agencies and the type of information they are collecting
are shown in Table 9.1.
Table 9.1: Major agencies and type of information collected
S.No. Agency Type of Information
1. National Nutrition Monitoring Diet and nutrition surveys Evaluation
Bureau (NNMB) of ongoing nutrition programmes
2. National Sample Survey Consumer expenditure surveys Socio-
Organisation (NSSO) economic survey Employment position
3. National Family Health Nutritional status, infant and child
Survey (NFHS) mortality and fertility
4. District Level Household Database on reproductive and child
Survey (DLHS) health at district level
5. Annual Health Survey Database on key household and
(AHS) demographic characteristics
6. Sample Registration System Data on birth rate, death rates and
(SRS) other fertility & mortality indicators
7. Food and Nutrition Board Diet and nutrition surveys
8. Registrar General of India Census data
Population statistics and trends
9. Directorate of Economics Food production, distribution, procurement
& Statistics (DES) and storage
Consumer price index
Food availability
10. Central Bureau of Healths Vital statistics
Intelligence (CBHI) Public health and medical statistics
Community health surveys
11. HANGaMA Survey Data on Nutritional status of children
190
Thus, you can see in Table 9.1 that organizations like National Nutrition Monitoring Nutrition Monitoring
and Nutrition
Bureau conducts diet and nutrition survey and evaluation of nutrition programmes. Out
Surveillance
of the organizations listed in Table 9.1, we would discuss the most notable seven
organizations. These are:
1. National Nutrition Monitoring Bureau (NNMB)
2. National Sample Survey Organization
3. National Family Health Survey (NFHS)
4. District Level Household Survey (DLHS)
5. Annual Health Survey (AHS)
6. Sample Registration System (SRS)
7. HUNGaMA Survey
Let us start with National Nutrition Monitoring Bureau.
1. National Nutrition Monitoring Bureau
The National Nutrition Monitoring Bureau (NNMB) was the only organization involved
in nutrition monitoring for the past 65 years. The Indian Council Medical Research
(Medical Research Council under the about Ministry of Health and Family Welfare,
Government of India) established NNMB in 10 states, in 1972, to periodically collect
information on the diet and nutritional status of communities and to evaluate various
national nutrition intervention programmes in operation. NNMB was located at the
National Institute of Nutrition, Hyderabad, India. Though it was in operation only in
10 states (Andhra Pradesh, Tamil Nadu, Uttar Pradesh, West Bengal, Kerala, Gujarat,
Maharashtra, Karnataka, Odisha) NNMB has been the only large-scale dynamic
database on diet and nutrition in the country providing information on nutritional status
of different age groups and dietary pattern at individual level. NNMB had two main
objectives. These are given as follows:
Objectives of NNMB
The objectives of NNMB were:
l To collect, on a continual basis, on representative segments of population in each

of the states, data on dietary pattern and nutritional status adopting standardized
and uniform procedures and techniques, and
l To periodically monitor and evaluate the ongoing national nutrition programmes,

to identify their strengths and weakness and to recommend mid-course appropriate
corrective measures to improve their effectiveness.
In pursuance of the first objective, the NNMB conducted surveys and has published
21 scientific reports between 1975 and 2003. From 1974 to 1981, in annual surveys
on a probability sample, a total of about 500 households each year (rural and urban)
were carried out in each State. In 1983, NNMB decided to link its sampling plan to
that of the National Sample Survey Organization (NSSO) of the Government of India.
The survey with the NSSO linked sampling plan was carried out in only four States
due to resource limitations. Individual dietary intakes were assessed using a single 24-
hour recall for estimating the intra-familial distribution of food. In the urban sample
of 250 households, a three-day weighment method was adopted for assessing the
dietary intake. Anthropometric data – height, weight, mid upper arm circumference
and fat fold at triceps – and data on clinical signs of nutritional deficiencies were
collected on all individuals in the selected households. 191
Public Nutrition In 1985-87, a survey was conducted exclusively in the Integrated Tribal Development
Project (ITDP) areas in the States of Kerala, Tamil Nadu, Karnataka, Andhra Pradesh,
Maharashtra, Gujarat, Odisha and West Bengal. This survey had the same objectives
as all the previous surveys. This survey was repeated in 1998-99 among the tribal
populations living in the same ITDP areas. Household dietary intake, anthropometry
and clinical signs of nutritional deficiency signs were assessed from all the households
in the sample. In 25 percent of the households, individual dietary intakes by a single
24-hour recall was done.
In 1988-90 and in 1996-97, two repeat surveys were carried out of the rural areas
surveyed in 1975-79 to generate longitudinal data on dietary intake, anthropometry and
clinical nutritional deficiency conditions in the rural population.
In 2000, using data from the surveys above, a separate report was produced on the
diet and nutritional status of adolescents (10 to 17 years of age). In 2001, the NNMB
took a decision to carry out diet and nutritional status surveys quinquennially (once
every five years) instead of annually. Intervening years between the quinquennial
surveys were to be utilized for carrying out surveys of special interest. Accordingly,
in 2001-2003 a survey of the prevalence of micronutrient deficiencies-Bitot Spots in
children 1-4 years, Iodine Deficiency Disorders in children 6-11 years and haemoglobin
level in preschool children, adolescent girls and pregnant and lactating women- was
carried out. Iodine content of salt samples from a sub-sample of households was
studied.
Currently in 2017, the first quinquennial survey of diet, nutritional intake and anthropometry
in the rural areas of the 16 States was carried out. For the first time, survey estimated
prevalence of obesity (using BMI, waist circumference and waist-hip ratio), hypertension
diabtes and dyslipidemia among urban population. Infant and young child feeding practices
(IYCF) among the mothers of < 3 year of children were also estimated.
NNMB was not a routine data collecting organization. It had several unique features.
These are given as follows:
Unique features of NNMB:
1. Organization of repeat surveys in 1988-90 and 1996-97, in the same villages in

all the states that were surveyed during 1975-79, to assess time trends in diet and
nutrition surveys.
2. Periodic generation of data on diet and nutritional status of socially vulnerable

groups of population like the tribals living in integrated tribal development project
areas, and the population physiologically at risk like elderly and adolescents.
3. Continuous collection of data on actual dietary intakes of families and individuals

belonging to different physiological and age groups, in different states. NNMB is
the only organization generating this type of data.
4. Assessment of intra-family distribution of foods and nutrients.
Regular generation of data by NNMB on various aspects as discussed above has been
very useful for the Planning Commission, Union and State governments and International
organizations. The changes in the nutritional status over a period time could be ascertained
with the help of NNMB surveys and the results so far indicate that over the last 25
years there has been gradual and significant reduction in the prevalence of both moderate
and severe forms of undernutrition as measured by anthropometry and clinical
assessment.
192 Let us discuss the second organization i.e. National Sample Survey Organization.
2. National Sample Survey Organization (NSSO) Nutrition Monitoring
and Nutrition
Surveillance
NSSO, a permanent survey organization, was set up in the Department of Statistics
of the Government of India in 1950 to assist in socioeconomic planning and policy
making, by collecting data on various facets of the Indian economy through nationwide
large-scale sample surveys. The NSSO has been carrying out Consumer Expenditure
Surveys quinquennially since 1972-73. As a part of these quinquennial surveys data
on dietary intake at National and State levels, and monthly per capita expenditure on
food are collected.
The data on food consumption per head is calculated from the data, which provide
information on per capita energy consumption for different states. In fact, the calculation
of the proportion of population below poverty line (indicator of poverty) is calculated
based on this information. It should be recognized that these data do not provide
individual dietary intakes of different age groups but indicate the availability at consumer
level. These data have been used to monitor the consumption expenditure over years.
This survey provides calorie, protein, and total fat intake per capita and per consumption
unit, using the two reference periods of 7 and 30 day immediately preceding the day
of the survey.
The NSSO data on nutritional intake gives data by rural and urban areas of States and
India on:
l Average quantity of consumption of different cereals per 30 days,
l Average value of these in rupees,
l Food security at the household level,
l Per capita and per consumption unit intake of calories, protein and fat per day,
l Percentage of total intake of protein and calorie from different groups of food
item,
l Distribution of households and individuals by calories intake level, and
l Cross-tabulations of the above by monthly consumption expenditure classes.
Let us next discuss the third organization i.e. National Family Health Survey.
3. National Family Health Survey (NFHS)
The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted
in a representative sample of households throughout India. All National Family Health Box 1 Highlights of NFHS
Surveys have been conducted under the stewardship of the Ministry of Health and
 NFHS-1 (1991)
Family Welfare, Government of India, with the International Institute for Population
 Infant feeding,
Sciences, Mumbai, serving as the nodal agency. The first survey was conducted in
 Child nutrition and
1991, since then second (1998-1999), third (2005-2006) and the most recent forth survey anthropometry of children
has been conducted in 2015-2016. The contents of previous rounds of NFHS is generally below 4 years
 NFHS-2 (1998-99)
retained and additional components are added from one round to another.
 Food consumption,
 Anthropometry and
The main objective of the first survey i.e. NFHS-1 was to provide data on infant and anaemia in women of
child mortality, family planning and to know about socioeconomic and demographic reproductive age group and
children (6 to 35 months)
indicators of children’s and mother’s health. NFHS-2 survey, conducted in 2005-06,
collected information on the quality of health and family welfare services, reproductive
health problems, the status of women, and domestic violence. Also, ever-married women 193
Public Nutrition and their children below three years of age had their haemoglobin levels measured to
provide the first national estimates of the prevalence of anaemia. A test was also conducted
 NFHS-4 (2015-16) in
addition to the above data for the iodine content of household cooking salt. NFHS-3 survey was carried out in
of NFHS-3, provides data on 2005-06 which provided data on fertility, maternal health care, perinatal mortality,
 Marriage and child feeding prevalence of HIV and tuberculosis, adolescent reproductive health, family life education
practices, delivery care,
immunization, domestic and women empowerment. Now, more recently NFHS-4 (2015-16) provides information
violence and nutrition on population, health and nutrition for each State/Union territory. For the first time it also
status of adults
 Blood sugar level and blood provided information for many important indicators like measurement of blood sugar
pressure measurement levels, blood pressure, knowledge about malaria control, abortions, domestic violence in
among adults (age 15-49
years) addition to the components covered in the earlier rounds. Highlights of each round of
NHFS are presented in the Box 1.
4. District Level Household Survey (DLHS)

Box 2 Highlights of
DLHS The Ministry of Health and Family Welfare (MOHFW), Government of India, initiated
District Level Household Surveys (DLHS) in 1997 to provide district level estimates on
 DLHS-1 (1998-99) health indicators to assists policy makers and program administrators in decentralized
 Maternal and child planning, monitoring and evaluation. In the series preceded by DLHS -1 in 1998-99 and
health, family planning
and other reproductive DLHS-2 in 2002-04, DLHS 3 in 2007-08 and the forth DLHS was carried out in 2011-
health services 12. DLHS-1 and DLHS-2 included data on the quality of public sector health services;
 DLHS-2 (2002-03) however, these were dropped in subsequent rounds. Several new themes were added to
 Anthropometry of DLHS-3, including sex education, age at marriage, infertility, obstetric fistula, knowledge
children below 72 months
and adolescent girls of about reproduction and public sector health programmes. In 2011-2012, DLHS-4 survey
10-19 years of age. was conducted which collected data on child malnutrition, health and morbidity of household
 Haemoglobin levels of
members including height, weight, blood pressure, blood sugar and haemoglobin levels
above two groups and
pregnant women (15 to 44). and data on life style diseases such as diabetes and blood pressure. Highlights of four
 DLHS-3 (2007-08) in surveys conducted by DLHS are presented in Box 2.
addition to above data
 Sex education, age at Let us discuss the next monitoring system i.e. Annual Health survey.
marriage, obstetric,
reproduction and public 5. Annual Health Survey (AHS)
health programmes.
 DLHS-4 (2011-12) The Annual Health Survey (AHS) was conceived during a meeting of the National
 Anthropometry of Commission of Population, held in 2005 under the Chairmanship of the Prime Minister.
children below 72
months including men The aim of survey was to monitor the performance of the government’s various health
and women above 18 interventions, including those under the National Rural Health Mission (NRHM), at
years of age.
relatively more frequent intervals. The first AHS was conducted in 2010-11.The data
 Blood pressure, blood
sugar and haemoglobin and estimates of 2010-11 have been used as baseline reference for assessment of health
levels in men and women and health care performance during first and second updation surveys of the AHS
above 18 years of age.
conducted in 2011-12 and 2012-13, respectively. The surveys elicited information on key
household and demographic characteristics including sex ratio, dependency ratio, and
effective literacy rate, legal age of marriage, schooling, drop outs and work participation
rate. The status of maternal health and health care services assessed through the indicators
of ante-natal care, delivery care, post-natal care, and maternal mortality. On the other
hand, to understand the status of child health and healthcare, the levels of immunization,
prevalence of low birth weight, breastfeeding practices, and supplementary nutrition are
estimated.
Data related to these parameters can be accessed at http://censusindia.gov.in/2011-

common/AHSurvey.html.
Do look them up. Now move on to the next monitoring system i.e. Sample Registration
System.
194
6. Sample Registration System (SRS) Nutrition Monitoring
and Nutrition
Surveillance
The Sample Registration System (SRS) is a large-scale demographic survey in the world
covering about 1.7 million households and 7.6 million populations. It is a joint effort of
Central and State Government. The SRS was initiated on a pilot basis by the Office of
the Registrar General, India in a few selected states in 1964-65, it became fully operational
during 1969-70. The survey provides reliable data from 1971 onwards about birth rate,
death rate and other fertility and mortality indicators at the national and sub-national
levels. The recent report of 2016 is the third in the series that has been prepared based on
data collected from new SRS sample units selected data from 2011 Census frame. Apart
from the fertility and mortality indicators, this Report includes data on crude birth rate,
crude death rate and infant mortality rates at Natural Division (group of contiguous districts)
level.
The latest SRS statistic report 2016 can be accessed at http://www.censusindia.gov.in/

vital_statistics/SRS_Reports__2016.html
From SRS we move on to the seventh monitoring system which is HUNGaMA survey.
7. HUNGaMA Survey
HUNGaMA is an initiative of Naandi Foundation that aims to create a hungama for

change in the fight against hunger and malnutrition. HUNGaMA Survey was conducted
in the year 2011, covering over 100 Indian districts to provide data on nutrition status of
children (0-59 months), and general household’s estimates including parent’s education,
type of house, access to services, food consumption etc. The Survey also collected data
pertaining to the feeding practices, hygiene habits and decision making power of the
mother’s and information about the Anganwadi centres along with the data on village
services and facilities.
More information about the HUNGaMA Survey can be accessed at https://

www.hungamaforchange.org/index.html
From our discussion above it must be clear that we have few organizations in
our country, which provide a more systematic approach in collection and
compilation of health and nutrition data. Before we proceed to the next topic, let us
check what we have learnt so far by answering the check your progress exercise given
herewith.
1. What is nutrition monitoring?
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
2. List the main objectives of nutrition monitoring.
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
195
Public Nutrition
3. List the seven notable organizations/systems involved with nutrition monitoring
in our country.
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
4. List the objectives and unique features of National Nutrition Monitoring Bureau.
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
Now we move on to the next topic i.e. Nutrition Surveillance System.
9.3 NUTRITION SURVEILLANCE SYSTEM (NSS)

Earlier in this unit we studied about nutrition monitoring. Nutrition monitoring you would
realize is usually an integral part of nutrition surveillance. Quite often, the terms “nutrition
surveillance” and “nutrition monitoring” as mentioned earlier too are used synonymously.
What then is nutrition surveillance? Nutrition surveillance means watching over
nutrition in order to make decisions, which will lead to improvement of nutritional
status of population.
Nutrition surveillance is a continuous and systematic process of collection, analysis,

interpretation of information to assess nutritional status and initiate appropriate
early action to promote optimal nutrition.
Nutrition monitoring is usually an integral part of nutrition surveillance and you already
know, it refers to “repeated measurements of the nutritional status, at regular
intervals of population or a specific group of individuals over a period of time.
‘Surveillance’, on the contrary, is concerned with data on the current status/ activities
at local levels for initiating action in response to events occurring during specific
programme implementation in the population". Nutrition surveillance, therefore,
encompasses analysis and action to promote better health and nutrition.
While studying about nutrition surveillance it is important for us to familiarize ourselves

with a term “Triple A Cycle”. What is Triple A? Let us find out. Triple A means
Assessment, Analysis and Action. Nutrition Surveillance is carried out adopting triple
A Cycle as indicated in Figure 9.1 herewith
Assessment
Action Analysis
196 Figure 9.1: The Triple A cycle

The first step in the cycle is assessment of the nutritional status of an individual, which Nutrition Monitoring
and Nutrition
is followed by analysis of the causes for deterioration in nutritional status. For example, Surveillance
the reasons could be delayed complementary feeding, inadequate dietary intake, frequent
attacks of morbidity and non-utilization of services provided by the government etc.
The health and nutrition workers should carefully enquire the reasons at the household
level and initiate suitable action, which is the next step in nutrition surveillance. The
action may be education of the mother about initiation of complementary feeding by
the age of 6 months or frequent feeding of energy rich foods or controlling morbidity.
The triple A cycle is not one time activity but a continuous process.
Having understood the concept of nutrition surveillance, let us now look at the objectives
and uses of nutrition surveillance. We will also discuss what infrastructure could be
used to establish NSS in the country. At the end, we would discuss the key indicators
and the importance of computerization in carrying out effective nutrition surveillance.
Let us now begin with the objectives of nutrition surveillance.
9.3.1 Objectives of Nutrition Surveillance

The main aim of nutrition surveillance is early identification of at risk groups of
population like children and mothers so as to institute appropriate interventions/
actions to prevent undernutrition. Thus, objectives of effective nutrition surveillance
are:
1. It should identify the prevalent nutrition-related problems and the high-risk groups.
2. The information collected in NSS should prompt initiation of appropriate intervention

programmes to prevent the occurrence of nutritional disorders. Surveillance should
never exist in isolation from action.
3. It also should provide information on nutrition and health of communities to help

in the preparation of action plans at different levels.
4. It should assist in the management and evaluation of health and nutrition related
programmes.
5. The nutrition surveillance should also be able to provide timely warning about
impending nutrition disasters.
Next, let us look at the uses of nutrition surveillance.
9.3.2 Uses of Nutrition Surveillance System

Nutrition surveillance system can have various uses. Some of the important uses
include:
1. The most important contribution of NSS is to help in early diagnosis, initiating of

prompt and immediate remedial measures to control undernutrition and thus
promote the nutritional status.
2. The NSS provides information on the current nutritional status, the geographic
distribution of nutrition problems (identification of geographic areas), causes and
changes in the prevalence/incidence over time, the actions initiated and their
effects.
3. The NSS can help to identify the seasons of nutritional stress.

197
Public Nutrition 4. The NSS can also be used for performance evaluation of the ongoing intervention
programmes and assessment of contributory factors.
5. It can help the administration in prioritizing actions, so as to modify policies and

programmes from time to time.
6. The NSS can provide information on nutritional trends over a period of time and
help in establishing a database on nutrition and related indicators to enable
assessment, constantly, of the extent of achievement of the national nutritional
goals.
We learnt about the objectives and uses of nutrition surveillance system. Let us now
study how we can institutionalize NSS i.e. what kind of infrastructure do we need
for NSS.
9.3.3 Infrastructure for Nutrition Surveillance System

The important step in the establishment of national NSS is identification of suitable
infrastructure. It would be preferred that we use an existing infrastructure rather than
establishing a new set up. In India, Integrated Child Development Services (ICDS) is
one of the largest nation-wide child development programmes. What is ICDS? You will
learn about it in detail in Unit 10. We will discuss here how it could be used to
develop NSS.
ICDS is best suited for developing NSS at the national level for the following reasons:
1. It is currently in operation in most of the community development blocks in the

country and, as per the National Nutrition Policy (NNP) it will be expanded to
the entire rural and 50% of the urban areas of the country.
2. It has the necessary infrastructure and trained manpower with a built-in

management information system from the village level up to the national level.
3. Growth monitoring, an important requisite to find out the nutritional status of

children is an integral part of ICDS. All the nutrition goals set by the NNP are
covered by the ICDS activities.
4. More importantly, ICDS has a built in Monthly Progress Reporting (MPR) system,
which could be an important tool for NSS.
What is Monthly Progress Reporting (MPR) system? Let us find out more about it.
Monthly Progress Reporting (MPR) system
At present, Anganwadi Workers (AWW) at the anganwadi centre (village) level monitor
the ICDS scheme through a system of monthly progress reports (MPR). The Supervisors
and the Child Development Project Officers (CDPOs) consolidate these MPRs. These
contain mostly quantitative information on the coverage under different components of
ICDS (Process variables). For effective NSS, there should be a provision to identify,
at different levels, “children at, risk” or “problem areas” so that corrective action could
be immediately initiated. Information should be collected about the reasons for low
coverage for various nutrition programmes like supplementary feeding programme,
semi-annual distribution of massive dose of vitamin A, nutritional anaemia control
programme, universal immunization programme etc. The information so collected should
help the workers in taking immediate action. Critical review of the MPRs is essential
at various levels i.e. village to the level of State, to improve the performance of the
198 programmes.
In addition to ICDS, the Department of Health, which has extensive infrastructure in Nutrition Monitoring
and Nutrition
the rural areas, can also be considered as the delivery mechanism for nutrition Surveillance
surveillance. In fact, the nutrition surveillance should be a combined approach both by
the Health and ICDS departments.
Thus, we saw how we could use the existing infrastructure for establishing NSS.
Now let us review the key indicators, which would be critical for a successful
nutrition surveillance programme.
9.3.4 Key Indicators of Successful Nutrition Surveillance

Programme
ICDS and Health department do collect information on several health and nutrition
indicators. However, we would mention here some key indicators which are critical
for a successful nutrition surveillance programme. These are:
l Enrolment and attendance of different beneficiaries for supplementary nutrition

and preschool education,
l Nutritional status of children and its trends,
l Growth faltering among children,
l Prevalence of nutritional deficiency signs like oedema (kwashiorkor), wasting

(marasmus), Bitot spots, night blindness and visible goitre.
l Coverage under national programmes namely:
a. Immunization of children and expectant women,
b. Vitamin ‘A’ distribution to children,
c. Distribution of IFA tablets to children, pregnant woman and lactating women.
l Prevalence of low birth weight,
l Vital rates in different age and physiological groups, and
l Prevalence of common morbidity in children and causes for deaths.
Thus, the indicators given above could provide necessary information on nutritional
status and coverage of target population in nutrition and health intervention programmes.
You probably know that computerization, like in any other programme, could help in
efficient delivery of NSS. Let us now study how could computerization help in
efficient delivery of NSS.
9.3.5 Computerization for Monitoring and Surveillance

The success of any surveillance programme depends on the regularity of submission
of the reports, assessment of their completeness and correctness and reviewing the
reports for further action. Manual compilation and consolidation of the data from
different AWCs/Sectors/Projects on a continuous basis is often time consuming, and
is liable to errors. Hence, a simple, user-friendly, computer software can be developed
to enable the concerned personnel at each project level to enter the surveillance
data on Personal Computers (PC) and obtain the necessary reports for assessing
the actual status and initiating appropriate action at every level. If the existing
NICNET services are utilized, the surveillance reports can be made available for
decision making to all the developmental agencies and the office of the District 199
Public Nutrition Collector. The district authorities can also utilize the information for preparation of
action plan for nutrition, and for targeting and reviewing the developmental programmes.
The software programme will also help in the performance appraisal and remedial
administrative measures. It also helps to present the data in a graphic form for easy
comprehension. A feedback mechanism would motivate the ICDS functionaries at
different levels and facilitate initiation of appropriate action without any time delay.
There is another important thing you have to remember is that the quality of the data
collected by different workers should be ensured. Therefore, all the workers involved
should be adequately trained in filling and interpretation of the MPRs and health-
related information. While all the fresh recruitees could be trained at the induction
level, those already in service should receive appropriate training. Training modules
may be necessary to ensure uniformity.
You will be happy to note that the National Nutrition Policy of the Government of India
and the National Plan of Action on Nutrition recommended establishment of National
Nutrition Surveillance System. The Tenth Five Year Plan also recommended an integrated
nutrition monitoring and surveillance programme through the existing resources and the
agencies.
Thus, in this unit we learnt about various aspects of nutrition monitoring and nutrition
surveillance. In the next unit, we will study about Nutrition Policy and Programmes
implemented by our government to eliminate malnutrition from the country.
1. What is Nutrition Surveillance?
...........................................................................................................................
...........................................................................................................................
2. Name two main infrastructure/systems in India that could provide a useful

delivery mechanism for NSS.
...........................................................................................................................
...........................................................................................................................
3. Mention key indicators that could be critical for successful nutrition surveillance
programme.
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
9.4 LET US SUM UP

We learnt in this unit that Nutrition monitoring is a tool to keep a watch on the
nutritional status of communities to assess the changes in nutritional status of communities
over a period of time. There are several organizations/programmes which collect
systematic information on nutrition, health and demography in our country. Most notable
among these are National Nutrition Monitoring Bureau, National Sample Survey
200 Organization and National Family Health Survey. This unit discusses in detail about
these three organizations and their activities related to nutrition monitoring. Nutrition Nutrition Monitoring
and Nutrition
surveillance is a continuous and systematic process of collection, analysis, interpretation Surveillance
of information to assess nutritional status and initiate appropriate early action to promote
optimal nutrition. Nutrition monitoring is an integral part of nutrition surveillance.
9.5 GLOSSARY
Encephalitis : general term used to describe a diffuse inflammation of
the brain and spinal cord, usually of viral origin, often
transmitted by mosquitoes.
Process variable : variables which measure certain activities or processes in

a programme.
Supplementary feeding : supplementary feeding means extra food which makes

up for a deficiency in the normally consumed diets of
individuals.

EXCERCISES
1. Nutrition Monitoring is a tool to keep a watch on the nutritional status of communities

to assess the changes in nutritional status of communities over a period of time.
2. The two main objectives of nutrition monitoring are:
l To assess the nutritional status of representative groups of communities on

a continuous basis in order to study the changes in the nutritional status, if
any; and
l To evaluate the various nutrition intervention programmes in operation to

determine the achievement or otherwise of the goals.
3. The 7 organizations include National Nutrition Monitoring Bureau (NNMB),

National Sample Survey Organization (NSSO), National Family Health Survey
(NFHS), District Level Household Survey (DLHS), Annual Health Survey (AHS),
Sample Registration System (SRS) and HUNGaMA Survey.
4. The objectives of NNMB include;
l To collect, on a continual basis, on representative segments of population in

each of the states data on dietary pattern and nutritional status adopting
standardized and uniform procedures and techniques, and
l To periodically evaluate the ongoing national nutrition programmes, to identify

their strengths and weakness and to recommend appropriate corrective
measures.
The Unique features of NNMB are:
1. Organization of repeat surveys in 1988-90 and 1996-97, in the same village in all
the states that were surveyed during 1975-79, to assess time trends in diet and
nutrition surveys.
201
Public Nutrition 2. Periodic generation of data on diet and nutritional status of socially vulnerable
groups of population like the tribals living in integrated tribal development project
areas, and the population physiologically at risk like elderly and adolescents.
3. Continuous collection of data on actual dietary intakes of families and individuals

belonging to different physiological and age groups, in different states. NNMB is
the only organization generating this type of data.
4. Assessment of intra-family distribution of foods and nutrients.
1. Nutrition surveillance is a continuous and systematic process of collection, analysis,

interpretation of information to assess nutritional status and initiate appropriate
early action to promote optimal nutrition.
2. In India, we have two infrastructures/systems that could be used to establish

NSS. These are Integrated Child Development Services (ICDS) and Health
Department.
3. Key indicators which are critical for a successful nutrition surveillance programme
are:
l Enrolment and attendance of different beneficiaries for supplementary nutrition

and preschool education.
l Nutritional status of children and its trends,
l Growth faltering among children;
l Prevalence of nutritional deficiency signs like oedema (kwashiorkor), wasting

(marasmus), Bitot spots, night blindness and visible goitre.
l Coverage under national programmes namely,
a. Immunization of children and expectant women,
b. Vitamin ‘A’ distribution to children,
c. Distribution of IFA tablets to children, pregnant woman and lactating

women.
l Prevalence of low birth weight,
l Vital rates in different age and physiological groups, and
l Prevalence of common morbidity in children and causes for deaths.
202
Nutrition Policy and
UNIT 10 NUTRITION POLICY AND Programmes
PROGRAMMES
Structure
10.1 Introduction
10.2 National Nutrition Policy
10.2.1 Aims of the National Nutrition Policy
10.2.2 Nutrition Policy Instruments
10.2.3 National Policy Implementation
10.3 Nutrition Programmes: An Overview
10.4 National Nutrition Mission (POSHAN ABHIYAAN)
10.5 Integrated Child Development Services (ICDS) Programme
10.6 Supplementary Feeding Programmes
10.6.1 National Programme of Nutritional Support to Primary Education (Mid-Day
Meal Programme)
10.6.2 Pradhan Mantri’s Gramodaya Yojana (PMGY)
10.7 Nutrient Deficiency Control Programmes
10.7.1 National Prophylaxis Programme for Prevention of Blindness due to
Vitamin A Deficiency
10.7.2 National Nutritional Anaemia Control Programme/National Iron Plus Initiative
(NIPI)
10.7.3 National Iodine Deficiency Disorders Control Programme (NIDDCP)
10.8 Infant and Young Child Nutrition Programme (IYCN)
10.8.1 Infant and Young Child Feeding (IYCF) Guidlines
10.8.2 Maternal Absolute Affection (MAA)
10.9 National Health Mission (NHM)
10.9.1 Reproductive, Maternal, New-born, Child and Adolescent
Health Programme (RMNCH+A)
10.9.2 Rashtriya Kishor Swasthya Karyakram (RKSK)
10.9.3 Janani Suraksha Yojna (JSY)
10.9.4 Janani Shishu Suraksha Karyakram (JSSK)
10.10 Food Security Programmes
10.10.1 Public Distribution System (PDS) and the Targeted Public
Distribution System (TPDS)
10.10.2 Antyodaya Anna Yojana (AAY)
10.10.3 Annapurna Scheme
10.10.4 National Food for Work Programme (NFFWP)
10.11 Self Employment and Wage Employment Schemes
10.11.1 Sampoorna Gramin Rojgar Yojana (SGRY) .
10.11.2 Swarnajayanthi Gram Swarozgar Yojana (SGSY)
10.11.3 National Rural Employment Guarantee Act 2005 (NREGA)
10.12 Let Us Sum Up
10.13 Glossary

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Public Nutrition
10.1 INTRODUCTION
In Units 7 and 8, we learnt about the various methods of assessment of nutritional
status. Unit 9 focused on the concept of monitoring and surveillance of nutritional
status. In this unit, we are going to study about the intervention programmes and
the policy of the Government of India (GOI), which is designed to ensure good
nutritional status of the population.
Widespread poverty resulting in chronic and persistent hunger is the single biggest
affliction of the developing world today. In India about 50 percent of the people
live below the poverty line and even after spending 80 percent of their income on
food, they cannot have a balanced diet. The physical expression of this continuously
re-enacted tragedy is the condition of under nutrition. In the face of continuing
poverty and malnutrition, a strategy of development, comprising a frontal attack on
poverty, unemployment and malnutrition, became a national priority. Various
intervention programmes have been launched by the government, to improve the
provision of basic services to the poor and to device a security system, through
which the most vulnerable section, viz. women and children, could be protected.
These programmes are discussed in this unit.
In 1993, the GOI adopted the National Nutrition Policy (NNP), in recognition of
the magnitude of under nutrition in the country. The salient feature of the NNP is
the other major focus in this unit.
Objectives
After studying this unit you will be able to:
l describe the national nutrition policy;
l enlist the various nutrition intervention programmes launched by the Government;
and
l discuss the major features of the nutrition intervention programmes.
10.2 NATIONAL NUTRITION POLICY

The National Nutrition Policy, formulated by the Department of Women and Child
Development, Government of India (GOI) was approved by the Cabinet in April
1993 and tabled in both houses of the parliament in August 1993. The policy
advocates a “comprehensive, integrated and inter-sectoral strategy for
alleviating the multifaceted problem of malnutrition and achieving the optimal
state of nutrition for the people”. The National Plan of Action on Nutrition
(NPAN) was released in 1995 to implement the National Nutrition Policy, which
included strategies specifically to address the prevention and control of micronutrient
deficiencies.
Let us now review the important aspects of the NNP. These include: a) Aims of
NNP, b) Nutrition Policy Instruments and c) Policy implementation. We shall begin
with the aims of NNP.
10.2.1 Aims of the National Nutrition Policy

The NNP is based on the conviction that reduction in malnutrition and improvement
in nutritional status of the people will contribute significantly to development of
human resources and the overall economic and social goals of the country.
The main aims of the NNP are:
l To draw attention to the urgent need to reduce malnutrition in the country
204
l To highlight the need for inter-sectoral coordination to achieve nutritional goals Nutrition Policy and
Programmes
l To orient relevant sectors to perceive nutrition as an outcome of their sectoral
activities, and
l To identify short term, intermediate and long-term strategies for achieving

nutritional goals either through direct policy changes or indirect institutional or
structural changes.
Next, let us get to know what nutrition policy instruments have been advocated for
achieving these above listed aims.
10.2.2 Nutrition Policy Instruments
Realizing the fact that nutrition is a multi-sectoral issue and needs to be tackled at
various levels, the nutrition policy instruments focused on tackling the problem of
nutrition both through nutrition interventions, for especially vulnerable groups, as
well as, through various development policy instruments that will create conditions
for improved nutrition. A direct intervention (short term strategy) and an indirect
policy instrument through long term institutional and structural changes were
advocated.
Let us then look at the nutrition policy instruments highlighting short and long- term
measures.
A. Direct Short Term Intervention
The short-term measures focus on the following strategies:
1. Nutrition intervention for specially vulnerable groups by a) expanding the
nutrition intervention net through Integrated Child Development Services (ICDS)
so as to cover all vulnerable children in the age group 0-6 years; b) Improving
growth monitoring between the age group 0-3 years in particular, with closer
involvement of the mothers, in a key intervention; c) Reaching the adolescent
girls through the ICDS so that they are made ready for a safe motherhood,
their nutritional status is improved and they are given some skill up-gradation
training in home-based skills and covered by non-formal education, particularly
nutrition and health education; d) Ensuring better coverage of expectant mothers,
such coverage to include supplementary nutrition starting from first trimester
of pregnancy to the first year after pregnancy.
2. Fortification of essential foods, for example, salt with iodine and/or iron.
3. Production and popularization of low cost nutritious foods from indigenous and
locally available raw material, by involving women in this activity
4. Control of micronutrient deficiencies among vulnerable groups - deficiencies
of vitamin A, iron, folic acid and iodine among children, pregnant women and
nursing mothers.
Next, let us look at the indirect policy instruments.
B. Indirect Policy Instruments
Long Term Institutional and Structural Changes
The long term strategies for achieving the national goals through indirect institutional
or structural changes includes:
i) Ensuring food security, a per capita availability of 215kg/person/year of food
grains.
ii) Improvement in the dietary patterns by promoting the production and increasing
the per capita availability of nutritionally rich foods.
205
Public Nutrition iii) Policies for effective income transfers so as to improve the entitlement package
of the rural and urban poor by re-orienting and restructuring the poverty
alleviation programmes (like Integrated Rural Development Programme) and
employment generation schemes (like Jawahar Rozgar Yojna etc.) to make a
forceful dent on the purchasing power of the lowest economic segments of
the population and by ensuring an equitable food distribution, through the
expansion of the public distribution system (PDS).
iv) Implementing land reforms.
v) Health and Family Welfare.
vi) Basic Nutrition and Health Knowledge, with special focus on wholesome
infant feeding practices.
vii) Prevention of food adulteration, by strengthening/gearing up the enforcement

machinery.
viii) Nutrition surveillance.
ix) Monitoring of nutrition programmes.
x) Communication through established media for effective implementation of the

nutrition policy.
xi) Ensuring an effective, minimum wage administration.
xii) Community participation, by involving the community through their panchayats

/beneficiary committees or through actual participation, particularly of women,
by promoting schemes relating to kitchen gardens, food preservation etc. and
generation of effective demand at the level of the community for all services
relating to nutrition.
xiii) Education and literacy, and
xiv) Improvement of the status of women.
The policy states that the measures enumerated above are to be administered
through inter-sectoral coordination and activities. Next, we will look at how the
National Nutrition Policy is being implemented.
10.2.3 National Policy Implementation

The nodal responsibility at the central level for policy implementation rests with the
Ministry of Human Resource Development under the chairmanship of Secretary,
Department of Women and Child Development. SectoralMinisteries/Departments
concerned like Agriculture, Food, Civil Supplies, Health and Family Welfare, Rural
Development, Education and Environment, whose role is crucial for sustainable
improvement in nutritional status of the population, are represented on the Inter-
Ministerial Coordination Committee. A National Nutrition Council is constituted
in the Planning Commission with the Prime Minister as its President and concerned
Union Ministers, a few State Ministers by rotation, and experts, representatives of
non-governmental organizations and grass root leaders (especially women) as its
members. Further, the effective implementation of the NNP is dependent to a large
extent on the State Governments/Union Territory Administrations and the constitution
of State Nutrition Councils.
From the above discussion it must be evident that we have a very comprehensive
national nutrition policy in place, which addresses malnutrition through multi sectoral
206 approach. In the next section, we will discuss the nutrition intervention programmes
designed and implemented by government of India. But first let us recapitulate Nutrition Policy and
Programmes
what we have learned so far.
1. List the main aims of National Nutrition Policy.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2. List any two direct short term interventions and two indirect policy instruments
of National Nutrition Policy.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3. NNP is implemented through a multisectoral approach. Elaborate.
.....................................................................................................................
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.....................................................................................................................
Now that we are aware about the Nutrition Policy, let us get to know about the
nutrition programmes being run by the government to combat malnutrition.
10.3 NUTRITION PROGRAMMES: AN OVERVIEW

The National Nutrition Policy, about which we have studied above, was formulated
only in 1993. However, prior to that, since the last four decades, Government has
launched a variety of nutrition intervention programmes to combat malnutrition.
One of the first nutrition programmes launched by the government was the Applied
Nutrition Programme (ANP), way back in 1963. Thereafter, numerous programmes
have been launched. Some of these programmes are in operation and some are
not. Some new programmes focusing on ensuring food security for all and
employment-based programmes have also been initiated by the government. We
will now study about all these programmes, under the following sections:
— National Nutrition Mission (POSHAN ABHIYAAN)
— Integrated Child Development Services (ICDS) Programme, which remains
one of the world’s most unique community based, outreach programme for
early childhood care and development.
— Food Supplementation Programmes (Mid day Meal Programme and Pradhan
Mantri Gramodaya Yojana).
— National Health Mission (NHM) 207
Public Nutrition — Nutrient Deficiency Control Programmes, namely National Prophylaxis
Programme for Prevention of Blindness due to Vitamin A deficiency, National
Nutritional Anaemia Control Programme, National Iodine Deficiency Disorder
(IDD) Control Programme.
— Infant and Young Child Nutrition Programme (IYCN) and Mothers Absolute
Affection (MAA).
— Food Security Programmes, namely Public Distribution System (PDS), Antodaya

Anna Yojana, Annapurna Scheme, National Food for Work Programme, and
— Self Employment and Wage Employment Schemes, namely Sampoorna Gramin.

Rojgar Yojana, Swarnajayanti Gram Swarajgar Yojana and National Rural
Employment Guarantee Act 2005 (NREGA)
We shall begin our exhaustive study of these programmes with a discussion on

Poshan Abhiyaan.
10.4 NATIONAL NUTRITION MISSION

(POSHAN ABHIYAAN)
To deal with the problem of malnutrition on a war footing, Government of India
approved setting-up of the National Nutrition Mission (NNM) on November 30th,
2017, which was then renamed as POSHAN Abhiyaan on May 25th, 2018. Poshan
Abhiyaan is a flagship programme of the Ministry of Women and Child Development
(MWCD) Government of India.
The POSHAN Abhiyaan aims to achieve the following objectives:
 To improve the nutritional status of children (0-6 years), adolescent girls,

pregnant women and lactating mothers in a time bound manner over a period
of three years beginning 2017-18.
 To reduce the prevalence of anaemia among the young children (6-59 months),
women and adolescent girls (15-49 years).
 To reduce the low birth weight during the next three years beginning with
2017-2018.
Major impact:
The programme targets to reduce stunting, undernutrition, anaemia (among young

children, women and adolescent girls) and reduce low birth weight by 2%, 2%, 3%
and 2% per annum, respectively. Mission would strive to achieve reduction in
Stunting from 38.4% (NFHS-4) to 25% by 2022 (Mission 25 by 2022).
Benefits & Coverage:
More than 10 crore people will be benefitted by this programme. All the States and
districts are covered in a phased manner i.e. 315 districts in 2017-18, 235 districts
in 2018-19 and remaining districts will be covered in 2019-20.
Implementation strategy
The implementation strategy is based on intense monitoring and convergence action

plan right upto the grass root level. NNM-POSHAN Abhiyaan is rolled out in three
phases from 2017-18 to 2019-20.
208
10.5 INTEGRATED CHILD DEVELOPMENT Programmes
SERVICES (ICDS) PROGRAMME

The Integrated Child Development Services is the world’s most unique welfare
programme, which holistically addresses health, nutrition and development needs of
young children, adolescent girls and pregnant/nursing mothers across the life cycle.
Launched by the Government of India in 1975-76, in 33 blocks, today, it has
expanded to 5652 community development blocks. Currently 7072 projects and
13.46 lakh anganwadi centres (AWC’s) are operational.
ICDS contributes not only to the achievement of women and child goals related to
health, nutrition and early child developmentbut also to other primary health care
goals and the goals of universal elementary education, as enunciated in the National
Plan of Action for Children 1992. Integration of services and consideration of the
mother and child as one ‘biological unit’ are the unique features of this programme.
We will look at the 1) objectives, 2) target groups, 3) programme components and,
4)implementation of ICDS. Let us begin with the objectives.
A. Objectives of the ICDS
The ICDS scheme aims at the holistic development of children in the age group
of 0-6 years, nursing and pregnant mothers belonging to the most deprived sections
of the society. The specific objectives of the ICDS are to:
l improve the nutritional and health status of children in the age group of 0–6
years and adolescents,
l lay the foundation for proper psychological, physical and social development
of the child,
l reduce the incidence of mortality, morbidity, malnutrition and school drop-out,
l achieve effective coordination of policy and implementation amongst the various
departments to promote child development, and
l enhance the capability of the mother to look after the health and nutritional
needs of the child through proper nutrition and health education.
Let us next learn about the beneficiaries who receives the benefits of the programme.
i.e. the target groups.
B. Target Groups
The main beneficiaries of the ICDS programme are:
l Children less then 3 years of age
l Children between 3-6 years of age
l Pregnant and Lactating women
l Adolescent Girls (11-18 years) and
l All women, 15-45 years of age.
We will now review the services and the components of the ICDS programme.
C. Programme Components and Interventions
ICDS programmes is a package of four major components: Early Childhood Care
Education & Development, Care and Nutrition Counsellling, Health Services and
Community Mobilisation, Awareness, Advocacy & IEC, as highlighted in the Figure
10.1.
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Public Nutrition
Figure 10.1: ICDS Components
Under each component various services are provided for the target beneficiaries as given in Table 10.1.
Table 10.1: Interventions/Activities of four major components of ICDS

Component 1 - Early Childhood Care Education & Development (ECCED)
Services Intervention/ Activities
Providing early - Provide non-formal preschool education activity based on semi structured play
childhood care and and learning method to channelize child’s energy.
education/Preschool
- Make children school ready with holistic development activities.
non-formal education
- Engage with Parents group / Mothers group to enable them train their children through
play mode.
- Conduct ECCE dayinvolve NGOs and School teachers in ECCE Days.
Supplementary - Provide morning snack, hot cooked meal and Take Home Ratio (THR) as per the
Nutrition (Bridge following norms: for children aged 6 months - 6 years (supplementary nutrition
between RDA and providing 500 calories and 12-15 g of proteins).
the Average Daily
Intake (ADI) of - Supplementary nutrition to be ensured for a minimum of 300 days in a year.
beneficiaries)
Component 2 - Care and Nutrition Counseling
Infant & Young Child - Advice on IYCF practices including breastfeeding for first six months of life and
feeding (IYCF) appropriate complementary feeding.
Promotion &
- One to one counseling through home visits.
Counseling
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Programmes
- Advice women on Food intake.
- Regular growth monitoring to examine optimal breastfeeding practices.
Maternal Care & - Supplementary nutrition to pregnant and lactating mothers to meet calorie/protein
Counselling gap, providing 600 Kcal and 18-20 g proteins.
- Early registration of pregnancy, monitoring weight gain and examination for pallor and
oedema and any danger signs.
- Lactation support for initiation of breastfeeding through skilled counselors
- Counselling and Behaviour Change Communication (BCC) to women regarding:
 Basic Health Care, Nutrition, Maternal Care and healthy food habits
 Appropriate diet, rest and IFA compliance during home visits
 Home based nutrition counselling to women (15 – 45 years), essentials for newborn
care and counselling on spacing
 Utilization of health services, family planning and environmental sanitation
Care, Nutrition, Health - Monthly health and nutrition education sessions

& Hygiene Education
- Education on improved caring practices – feeding, health and hygiene and psychosocial
- Knowledge sharing for care during pregnancy, lactation and adolescence
- Promotion of local foods, appropriate food demonstration and family feeding
- Celebration of Nutrition week, Breastfeeding week, ICDS day etc.
- Weighing of children 0-3 years on monthly basis and 0-6 years children on quarterly
basis and maintain growth charts (as per WHO Child Growth Standards) for all children
(0-6 years)
- Identifying growth faltering and appropriate counselling of care givers on optimal infant
and young child feeding and health
- Providing joint Mother and Child Protection card to each mother to track the nutritional
status, immunization schedule and developmental milestones for both child and pregnant
and lactating mothers
Community based care - 100% Weighing of all eligible children and identification of underweight children
and management of - Referral to NRCs/MTCs for children requiring medical attention
Underweight Children
- 12 day nutritional counseling and care sessions for required children (Sneha Shivirs)
&18 day home care and follow up during home visit.
- Supplementary nutrition to the Severely Malnourished Children (SAM) (6 months - 72

months) providing 800 Kcal and 20-25 g protein.
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Public Nutrition
Component 3 - Health Services
Immunization and - Ensure immunization of pregnant women (TT) and infants.

Micronutrient
- Children (9 months-5 years) to given Vitamin A and Booster Doses as per the national
Supplementation
immunization schedule
- IFA supplementation (infants after 6 months of age)
- Deworming as per guidelines & Counselling
- Organizing and conducting fixed day immunization sessions, known as “Village Health
Nutrition Days (VHND)” at the AWC
Health Check-up - Antenatal Care (ANC)/ Post Natal Care (PNC)/Janani Suraksha Yojna (JSY)
- Support for Integrated Management of Neonatal & Childhood Illness (IMNCI)/ Janani
Shishu Suraksha Karyakram (JSSK)
- Identification of severely underweight children requiring medical attention & support
- Carry out regular health check-ups, recording weight, immunization, support to community
based management of malnutrition, treatment of diarrhoea, deworming and distribution
of iron and folic acid and medicines for minor illness.
- AWC to control common ailments like fever, cold, cough, worm infestation etc. including
medicines and basic equipment for first aid.
Referral Services - During health check-ups and growth monitoring sessions refer sick and malnourished
children as well as pregnant lactating mothers in need of prompt medical attention, to the
Health facilities.
Component 4- Community Mobilisation, Awareness, Advocacy & IEC
IEC, Campaignsand - Information dissemination & awareness generation on entitlements, behaviours & practices
Drives etc.
- Sharing of nutritional status of children at Gram Sabhas meetings
- Linkage with Village Health Sanitation & Nutrition Committee (VHSNC), Action Groups,
Community
- Sensitization and engagement of PRIs/SHGs/Mothers.
- Social mobilisation campaign in partnership with Song and Drama Division in tribal areas,
rural areas.
- Use of mainstream media channels like TV, radio, print media, newsletter etc. for
propagating good practices of child & women health.
- Interpersonal Communication through home visits, the mothers-in-law, mother and other
care givers are also sensitised to ensure appropriate care and feeding practices at home.
Having gone through Table 10.1, you would be aware that the main services provided under ICDS are early
childhood care, supplementary nutrition, immunization, health check-ups, referral services, growth monitoring
etc. Along with all these components ICDS also have provisions for adolescent’s girls as summarized in
Figure 10.2.
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Programmes
Fig. 10.2: ICDS target groups and components
A brief review about the Adolescents Girls Schemes under the ICDS infrastructure
is provided next.
Adolescent Girls Scheme:
The Adolescent Girls (AG) Scheme under ICDS primarily aims at breaking the
inter-generational life cycle of nutritional and gender disadvantage and providing a
supportive environment for self-development.
The AG Scheme has been revised and renamed as Kishori Shakti Yojna (KSY) and
put into operation from November, 1991. The programmes covers all unmarried
adolescent girls (11-18 years) whose family’s income is below Rs. 6400 per annum
as the beneficiaries of the program. Services provided are educational activities
through nonformal and functioned literacy pattern, immunization, and general health
checkup every 6 months, treatment for minor ailments, deworming, prophylaxis
measures against anaemia, goitre, vitamin deficiencies, etc., referral to Public Health
Centres (PHC)/district hospital in the case of acute need, and convergence with
Reproductive Child Health Scheme.
Another scheme for adolescents has been implemented using the platform of ICDS
through anganwadi centres is Rajiv Gandhi Scheme for Empowerment of Adolescent
Girls, ‘SABLA’.
Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG)
or SABLA
SABLA was implemented in the year 2011. It focuses on all out-of-school adolescent
girls. The objectives are to enable the adolescent’s girls for self development and
empowerment, to improve their nutrition and health status, promote awareness
about health, hygiene, nutrition, reproductive/sexual health, life skills and tie up with
National Skill Development program (NSDP) for vocational skills, mainstreaming
out-of-school adolescent girls into formal/nonformal education and to provide
information about existing public services (PHC/community health centres/Post
office/Bank/Police station).
213
Public Nutrition Services provided are nutrition provision of 600 calories, 18-20 g of protein and
micronutrients per day for 300 days in a year, iron and folic acid supplementation,
health checkup and referral services: Kishori Diwas, Nutrition and Health Education
(NHE), counselling/guidance on family welfare, ARSH, child care practices and
home management, life skill education and accessing public services and vocational
training for girls aged 16 and above under NSDP.
Besides the adolescent girl, scheme under the ICDS, since 2017, a maternity
benefit programme has been implemented in all districts of the country in accordance
with the provision of the National Food Security Act, 2013. The programme is
named as ‘Pradhan Mantri Matru Vandana Yojana (PMMVY), which has been
envisaged to be implemented using the platform of Anganwadi service schemes
under ICDS. A brief review on PMMVY follows:
Pradhan Mantri Matru Vandana Yojana (PMMVY)
PMMVY is a centrally sponsored scheme, which provides grant-in-aid directly in
accounts of pregnant women and lactating mothers (PW/LM) who are the
beneficiaries of this programme.
The objectives of PMMVY include:
l Providing partial compensation for the wage loss in terms of cash incentives
so that the woman can take adequate rest before and after delivery of the
first living child.
l The cash incentive provided would lead to improved health seeking behaviour
amongst the Pregnant Women and Lactating Mothers (PW&LM).
The benefits under PMMVY include:
PW & LM shall receive a cash incentive of Rs 5000-/ in three installments at the
different stages as specified in Table 10.2.
Table 10.2: Conditions and Installments for PW/LM enrolled under PMMVY
Conditionalities and installments
Installments Condition Amount

(in Rupees)
First installment Early registration of pregnancy 1000-/
Second installment Received at least one ANC
(can be claimed after 6 months
of pregnancy) 2000-/
Third installment i. Child Birth is registered
ii. Child has received first cycle of
BCG, OPV, DPT and Hepatitis-B or
its equivalent/substitute 2000-/-
The eligible beneficiaries would receive the remaining cash incentives as per
approved norms towards maternity benefit under Janani Suraksha Yojana (JSY) after
institutional delivery so that on an average, a woman will get Rs. 6000/- .
D. Programme implementation
The ICDS programme is implemented, at the central level, by the Department of
Women and Child Development, Ministry of Human Resource Development in
coordination with the Ministry of Health. At the State level, implementation is the
responsibility of either the Department of Social Welfare/Women and Child
Development/Health or a separate Directorate of ICDS. The programme
214 infrastructure along with the designation of the programme functionaries at the
Block to Village/Community levels is presented in Figure 10.3. The Anganwadi Nutrition Policy and
center (AWC) – a courtyard play center – is the symbol of Government systems Programmes
and services, closest to disadvantaged communities, at village/hamlet level. It is
the focal point for converging various government programmes for young children,
girls and women from disadvantaged communities. The Anganwadi Worker assumes
a pivotal role in the ICDS structure due to her close and continuous contact with
the community. As the crucial link between the community and the government
administration, she becomes a central figure in asserting and meeting the needs of
the community she lives in.
Figure 10.3: ICDS infrastrucure
From our study so far you would have realised that ICDS is a unique and largest
programme in the world providing integrated services which holistically address the
health, nutrition and development needs of young children, adolescent girls and
pregnant/nursing mothers. In the next section, we would discuss the supplementary
feeding programmes of the government of India. But first let us answer the questions
given in check your progress exercise 2 to assess our learning of this section.

1. List the various nutrition programmes launched by our government to combat
malnutrition.
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Public Nutrition
2. Enumerate the goals/objectives of ICDS .
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3. Write the programme components of the ICDS.
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4. What are the objectives of PMMVY?
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10.6 SUPPLEMENTARY FEEDING PROGRAMMES

Food supplementation programmes have a very important role to play combating
malnutrition. The aim of these supplementary feeding programmes is to improve
the nutritional status of vulnerable groups through distribution of food supplements.
Different types of supplementary feeding programmes have evolved over the years
as short-term measures to combat malnutrition. Some of these are on going and
some are no longer in operation now. We will study about the following supplementary
feeding programmes in this section:
1. National Programme of Nutritional Support to Primary Education (Mid-Day
Meal Programme).
2. Pradhan Mantri’s Gramodaya Yojana (PMGY)
Let us get to know about these programmes then.
10.6.1 National Programme of Nutritional Support to Primary

Education (Mid-Day Meal Programme)
The National Programme of Nutritional Support to Primary Education commonly
known as Mid-Day Meal (MDM) programme was launched in August, 1995
consequent to the favourable impact of the scheme on children in some States, as
well as, the comfortable food stock position in the country, and to relate primary
education with nutrition, health and ICDS.
The mid day meal programme is one of the most important ongoing feeding
programmes organized by the Department of School Education and Literacy not
only to improve nutritional status of school children but also to attract poor children
to school. Further, school age children are in a phase of rapid growth and
development. Their nutritional needs are considerable. However, children,
particularly from poor families, do not get enough food to eat. Their home diets
216 are often inadequate. Many, especially in rural areas, come to school partly hungry
and some even on empty stomach, trekking long distances. Under such Nutrition Policy and
Programmes
circumstances, they are unable to concentrate on the studies and benefit from the
education. Hence, providing a supplement in school would complement the home
diet and sustain the interest of children in learning so that drop out rates are
lowered and school attendance improves. We would study about the objectives,
target group, programme component and strategy of MDM programme. Let us
look at the objectives first.
Objectives
The programme is intended to give a boost to universalisation of primary education
by increasing enrolment, retention and attendance and simultaneously impacting
upon nutritional status of students in primary classes.
Target Group
All students of primary classes (I-V) in the Government, Local Body and
Government aided schools in the country are covered in all States/UTs (except
Lakshadweep). From October 2002, the programme has been extended to children
studying in Education Guarantee Scheme and Alternative and Innovative Education
(EGS&AIE) Centres. Private Un-aided schools are not covered under the
programme. The main beneficiaries of the programme are therefore school children
between 6-11 years of age attending elementary/primary schools. In 2007, GOI
extended the mid-day meal scheme to cover children in upper primary class in
3479 Educationally Backward Blocks (EBBS), which was than further revised in
2009-10 to cover the children studying in National Child Labour Project (NCLP)
Schools also.
Let us now review the programme component and strategy.
Programme Component
To achieve the above objectives a cooked mid day meal with nutritional content as
shown in Table 10.3 is provided to all children studying in classes I – VIII.
Table 10.3: Recommended food amount and nutrient content of MDM/day/
child
Class Amount Calorie Protein Amount Amount of Oil &
of the of Content Content of Vegetable Fat
Children Food Grain (Kcal) (g) Pulses (g) (g) (g)
I-V 100 450 12 20 50 5

(Primary)
VI-VIII 150 700 20 30 75 7.5

(Upper
Primary)
The food supplements provided through the programme vary from ready-to-eat
food like fruit bread etc. to cooked food like ‘upma’ or ‘khichri’ or others, which
are convenient to eat. In Tamil Nadu, traditional ‘rice-sambar’ preparation is used
in the programme. In Rajasthan ghugri (porridge) is being provided. Whereas, in
the State and Delhi a six day cycle menu of cooked foods is being used for
MDMP. The raw materials supplied by the international agencies include corn
soya meal (CSM), wheat soya blend, soya fortified bulgar (SFB) and salad oil. The
programme was conceived for inculcating the qualities of discipline, comradeship,
good food and healthy habits and knowledge about nutrition through the provision
of nutritious meal daily.
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Public Nutrition Programme Implementation
The programme is operated by the Department of Education and is being implemented
through Panchayats and Nagarpalikas. The feeding is usually carried out within the
school premises. The school teacher is responsible for the distribution of food and
maintenance of records such as food stock register, health cards and attendance
register relevant to the programme. Cook cum helper are responsible for cooking
the meals for schools, two cooks-cum-helper for schools with 26 to 100 students
and one additional cook-cum-helper for every additional of upto 100 students is
provides. The revised guidelines have a provision of financial support upto a
maximum of Rs. 60,000/- per shed, for the construction of Kitchen sheds. A one
time grant of Rs 5,000/- per school towards assistance for cooking/kitchen devices
such as gas stoves with connection, stainless steel water storage tank, cooking and
serving utensile, etc. are given. Also, subsidy for transportation of food grains is
provided to 11 special category states at PDS rates and up to a maximum of
Rs.75.00 per quintal for other than special categories States/UTs.
We will now go over to the next supplementary feeding programme. i.e Pradhan
Mantri’s Gramodaya Yojana (PMGY).
10.6.2 Pradhan Mantri’s Gramodaya Yojana (PMGY)
In order to achieve the objective of sustainable human development at the village
level, a new initiative in the form of Pradhan Mantri’s GramodayaYojana (PMGY)
has been introduced in the Annual Plan 2000-01. This focuses on the creation of
social and economic infrastructure in five critical areas with the objective of
improving the quality of life of our people specially in rural areas. Schemes related
to health, nutrition, education, drinking water, housing and rural roads are undertaken
within this programme. The PMGY has two components: Programmes for rural
connectivity with 50 percent allocation, and other programmes of primary health,
primary education, rural shelter, rural drinking water and nutrition with the remaining
50 percent allocation.
The PMGY envisages allocations for Additional Central Assistance (ACA) for
selected basic minimum services in order to focus on certain priority areas including
nutrition. The allocation under nutrition component of PMGY, which is essentially
meant as an additionality for providing the complete nutritional requirements to all
below poverty line (BPL) children in the age group of 6 months to 3 years only,
is to be made under the Supplementary Nutrition Programme component of ICDS.
The minimum allocation for Nutrition Component is 15% of the Additional Central
Assistance for PMGY.
Let us now do an exercise to recapitulate our knowledge.
1. Read the following carefully and mention whether true or false and correct
a. Mid day meal programme was launched not only to improve nutritional
status of children but also to attract poor children to school.
b. The department of women and child development operates the mid day
meal programme.
c. The nutrition component of PMGY is to be made under the supplementary
nutrition programme component of the ICDS.
2. Enumerate the Programme Component of MDM programme.
..................................................................................................................
..................................................................................................................
..................................................................................................................
218
10.7 NUTRIENT DEFICIENCY CONTROL Programmes
PROGRAMMES
The Government of India has implemented various prophylaxis (preventive)
programmes to combat malnutrition. Under these schemes, commercially prepared
vitamins and minerals are supplied to vulnerable sections of the population through
organized programmes. These programmes are known as Nutrient Deficiency
Control Programmes.
The three important ongoing nutrient deficiency control programmes are:
1) National Prophylaxis Programme for Prevention of Blindness due to Vitamin
A deficiency
2) National Nutritional Anaemia Control Programme, and
3) National Iodine Deficiency Disorder Control Programme (NIDDCP).
We will now discuss the important aspects of these programmes such as objectives,
target group, programme strategy and implementation. Let us begin with the National
Prophylaxis Programme for Prevention of Blindness due to Vitamin A deficiency
10.7.1 National Prophylaxis Programme for Prevention of

Blindness due to Vitamin A Deficiency
You have read in Unit 3 that Vitamin A deficiency has been recognized to be
a major controllable public health nutritional problem. In India, milder forms
of vitamin A deficiency affecting conjunctiva, like bitot spots are observed in about
15% preschool children. According to WHO, >0.5% prevalence of bitot spot in
preschool children is indicative of public health significance. Longitudinal community
studies reveal that in some parts of the country, the incidence of corneal
xerophthalmia is about 0.5 to 1 per 1000 preschool children. It is estimated that
about 30-40,000 children in the country are at risk of developing nutritional blindness
every year. In recent years, however, there appears to be a significant change in
the profile of vitamin A deficiency. The repeat survey of the National Nutrition
Monitoring Bureau (NNMB) carried out in 2011-12 indicated a decline of bitol spot
from about 2% in 1975-79 to about 0.2% amongst preschool children. It is,
however, important to understand that even mild vitamin A deficiency probably
increases morbidity and mortality in children, emphasizing the public health importance
of this disorder. Hence, there is a need for the National Prophylaxis Programme
for the prevention of Nutritional Blindness due to vitamin A deficiency. Let us look
at the objective of the programme.
Objective
The National Prophylaxis Programme for the Prevention of Nutritional Blindness
due to vitamin A deficiency aims at protecting children 9 months to 5 years at risk
from vitamin A deficiency. Let us look at the target group of the programme.
Target Group
All children, of 9 months to 5 years, particularly those living in rural, tribal and
urban slum areas, are beneficiaries of the programme. Next, let us review the
programme strategy.
Programme Strategy
The programme focuses on two strategies a) prevention of Vitamin A deficiency
and b) treatment of Vitamin A deficiency. Let us study each strategy in detail.
219
Public Nutrition a) Prevention of Vitamin A Deficiency
The prevention strategy within the programme comprises a long-term and a short-
term intervention. While the short-term intervention focuses on administration of
mega dose of vitamin A on periodic basis, dietary improvement is the long-term
ultimate solution to the problem of vitamin A deficiency. We will study the long-
term intervention first i.e promotion of consumption of Vitamin A rich foods.
i) Long term intervention-Promoting consumption of vitamin A rich foods:
Actionpoints under this intervention include that:
 Regular dietary intake of vitamin A rich foods by pregnant and lactating
mothers and by children under 5 years of age must be promoted,
 The mothers attending antenatal clinics and immunization sessions, as
well as, mothers and children enrolled in the ICDS Programme must be
made aware of the importance of preventing vitamin A deficiency,
 Breastfeeding including feeding of colostrums must be encouraged,
 Feeding of locally available -carotene (precursor of vitamin A) rich
food such as green leafy vegetables and yellow and orange vegetables
and fruits like pumpkin, carrots, papaya, mango, oranges etc. along with
cereals and pulses to a weaning child must be promoted widely. In
addition, whenever, economically feasible, consumption of milk, cheese,
paneer, yoghurt, ghee, eggs, liver etc. must be promoted.
For increasing availability of vitamin A rich food, growing of vitamin A rich foods
in home gardens and consumption of these must be promoted.
We will now study the short term intervention i.e. administration of massive dose
of vitamin A.
ii) Short term intervention-administering massive dose of vitamin A :
Administration of massive dose of vitamin A to preschool children at periodic
intervals is a simple, effective and most direct intervention strategy. This is a
short-term strategy. Unlike most other micronutrients, vitamin A is stored in
the body for prolonged periods and hence periodic administration of massive
dose ensures adequate vitamin A nutrition.
 Under the massive dose programme, every infant 6-11 months and children
1-6 years is to be administered vitamin A every 6 months. Priority is to
be given for coverage of children 9 months to 3 years since the highest
prevalence of clinical signs of vitamin A deficiency is reported in this age
group. The recommended schedule is as follows:
9 months — one dose of 100000 IU with measles immunization
16-18 months — 200000 IU wih DPT booster
Every 6 months upto 5 years of age - 200000 IU
Thus, a total of 9 mega doses are to be given from 9 months of age upto
5 years.
The contact with an infant during administration of measles vaccine at
the age of 9 months is considered a practical time for administering the
vitamin A supplement
 A camp approach may be used for administering vitamin A to
children 1-3 years and 3 - 5 years. However, the DPT/OPV booster in
mid-second year to a child is a suitable time for the second dose of
220
vitamin A (200000 IU). The 9th and 10th plan recommends the Nutrition Policy and
Programmes
administration of Vitamin A drops to children 9 months-36 months of age
through RSSK/ICDS system.
We will now study the second strategy i.e. treatment of vitamin A deficiency.
b) Treatment of Vitamin A deficiency
All children with clinical signs of vitamin A deficiency must be treated as early as
possible. Treatment schedule includes:
— Single oral dose of 200 000 IU of vitamin A immediately at diagnosis
— Follow up dose of 200 000 IU 1-4 weeks later.
Infants and young children suffering from diarrhoea, measles or acute respiratory
infections must be monitored closely and encouraged to consume vitamin A rich
food. In case, early signs of vitamin A deficiency are observed, the above treatment
schedule must be followed. We will now study the implementation strategy of the
vitamin A programme.
Implementation Strategy
The National Prophylaxis Programme for the prevention of Nutritional Blindness
due to vitamin A deficiency is implemented through the Primary Health Centers
and sub-centers. The multi-purpose worker (F) and other paramedicals working
in the Primary Health Centers are responsible for administrating vitamin A
concentrates to children under 5 years and for imparting nutrition education. The
services of ICDS, under the Department of Women and Child Development, Ministry
of Welfare, is utilized for the distribution of vitamin A to children in the ICDS
Blocks and for the education of mothers on prevention of vitamin A deficiency.
The Mother-Infant Immunization Card/Mother  Child Protection Card is used to
record and monitor the administration of vitamin A dose to children under two
years. The Growth Monitoring Card/Register used for monitoring the growth of
children under the ICDS programme, is used for recording and monitoring
administration of vitamin A solution till the age of five years. We will now study
the second nutrient deficiency control programme. i.e National Nutritional Anaemia
Control Programme.
10.7.2 National Nutritional Anaemia Control Programme/National

Iron Plus Initiative (NIPI)
You have read in Unit 3 in nutritional problems that nutritional anaemia is a serious
public health problem. Although, anaemia is widespread in the country, it especially
affects women in the reproductive age group and young children. It is estimated
that over 50 percent of pregnant women are anaemic. Nutritional anaemia, due to
iron and folic acid deficiency, is directly or indirectly responsible for about 20
percent of maternal deaths. Recently the NFHS-4 (2015-16) data revealed that
59% of children (6-59 months) had heamoglobin levels below 11 g/dl, 28% mild,
29% moderate and 2% had sever anaemia. Anaemia is a major contributory cause
of high incidence of premature births, low birth weight and perinatal mortality. To
reduce the prevalence of anaemia in pregnancy the National Nutritional Anaemia
prophylaxis programme of iron and folic acid distribution to pregnant mothers was
initiated by Government of India in 1972.
More recently a comprehensive set of actions have been identified in national
guidelines for control of iron deficiency aneamia in the form of National Iron +
Initiative (NIPI). The NIPI is an attempt to look at iron deficiency comprehending
across all life stages including adolescents and women in reproductive age groups.
221
Public Nutrition Let us look at the objectives of the programme.
Objectives
The National Nutritional Anaemia Control Programme aimed at significantly
decreasing the prevalence and incidence of anaemia in women in reproductive age
group, especially pregnant and lactating women, and preschool children. Let us
look at the target group of the programme.
Target Group
The beneficiaries of the programmeincluded :
 Women in the reproductive age group, particularly pregnant and lactating
mothers
 Children 1-5 years of age
 Adolescent Girls
 Family planning acceptors (women who accept family planning measures like
intrauterine devices (IUD) and tubectomy)
We will now look at the programme strategies.
Programme Strategy
The programme focuses on primarily three strategies: a) Promotion of regular
consumption of foods rich in iron b) Promotion of consumption of iron and folic
acid supplements to the ‘high risk’ groups and c) Identification and treatment of
severely anaemic cases. We will study each strategy briefly now. Let us start with
the first strategy i.e. Promotion of regular consumption of foods rich in iron.
a) Promotion of regular consumption of foods rich in iron. Various action
points under this strategy include:
 Regular dietary intake of iron and folic acid rich foods by pregnant and
lactating women, adolescent girls and children under 5 years of age must be
promoted.
 Regular consumption of iron rich foods such as green leafy vegetables (such
as mustard leaves(sarsoks sag), amaranth (chaulai sag), colocasia (arbi) leaves,
knoll khol greens (Ganth Gobi ka sag), bengal gram greens (chana sag), turnip
greens (shalgam ka sag), cereals (such as wheat, ragi, jowar, bajra), pulses,
especially sprouted pulses and jaggery (gur) must be promoted widely. In
addition, wherever culturally and economically feasible, consumption of animal
foods such as meat, liver, poultry etc. must be encouraged.
 Ensure incorporation of iron rich foods such as green leafy vegetables in the
weaning foods of infants.
 Vitamin C (ascorbic acid) promotes absorption of iron. Regular consumption
of vitamin C rich foods such as lemon, orange, guava, amla, green mango
along with iron rich foods must be promoted.
 For increasing availability of iron rich foods, growing of iron rich foods in
home gardens and consumption of these must be promoted.
 Tea inhibits absorption of iron. Advice a reduce consumption of tea, specially
during pregnancy, for improving the absorption of iron and prevention of
anaemia. Let us discuss the second strategy now.
b) Promoting consumption of iron and folic acid supplements to the ‘high
risk’ groups.
222
As a priority, all pregnant women, irrespective of haemoglobin levels, must be Nutrition Policy and
Programmes
provided with the recommended dose of iron and folic acid (folifer) supplements.
Preschool children, especially those in tribal areas and ICDS blocks, should be
given on priority the recommended dosage of iron and folic acid supplements. The
National Iron Plus Initiative (NIPI) aims to reach the following age groups:
1. Bi-weekly iron supplementation for children in the age group of 6–60 months
2. Bi-weekly iron supplementation for preschool children 6 months to 5 years
3. Weekly supplementation for children from 1st to 5th grade in Govt. & Govt.
aided schools
4. Weekly supplementation for out of school children (5–10 years) at Anganwadi
Centres
5. Weekly supplementation for adolescents (10–19 years)
6. Daily supplementation for pregnant and lactating women
7. Weekly supplementation for women in reproductive age
The recommended doses of folic acid and iron supplements are given in Table
10.4.
Table 10.4: Recommended doses of iron and folic acid supplement
Age Group Intervention /Dose Regime Service Delivery
6–60 months 1ml of IFA syrup Biweekly throughout Through ASHA

containing 20 mg of the period 6–60 Inclusion in MCP
elemental iron and months of age and card
100 mcg of folic acid de-worming for
children 12 months
and above.
5–10 years Tablets of 45 mg Weekly throughout In school through

elemental iron and the period 6–10 teachers and for out-
400 mcg of folic acid years of age and of school children
biannual de-worming through Anganwadi
centre (AWC)
Mobilization
by ASHA
10–19 years 100 mg elemental Weekly throughout In school through

iron and 500 mcg the period 10–19 teachers and for those
of folic acid years of age and out-of-school through
biannual de-worming AWC Mobilization
by ASHA
Pregnant and 100 mg elemental 1 tablet daily for 100 ANC/ ANM /ASHA
lactating iron days, starting after Inclusion in MCP
card and 500 mcg of the first trimester, at
women folic acid 14–16 weeks of
gestation. To be
repeated for 100
days post-partum.
Women in 100 mg elemental Weekly throughout Through ASHA
reproductive iron and 500 mcg of the reproductive during house visit
age (WRA) folic acid period for contraceptive
distribution
Source: Guidelines for control of Iron Deficiency Anaemia, NRHM, 2013 223
Public Nutrition Let us go over to the third strategy.
c) Identification and treatment of severely anaemic cases
Women with haemoglobin levels below 7g/dl are considered to be severely anaemic.
Testing of blood for haemoglobin concentration at field level is neither considered
safe or practical. Therefore, as far as possible, severely anaemic cases should be
identified on the basis of clinical signs. All health workers should be trained to
identify such anaemic cases. Further, cases of severe anaemia should be referred
to the PHC medical officer for diagnosis of the causative factors and treatment.
Recommended therapeutic dose for women in the reproductive age group is three
adult tablet per day for a minimum of 100 days. Also albendozole (400 mg) tablet
for biannual de-warming for helminthic control is recommended. We will now study
how the programme is implemented in the field.
Programme Implementation
The programme is implemented through the Primary Health Centres and its sub-
centres under the National Health Mission (about which you will learn in sub-
section 10.9). The Multipurpoe Worker (F) and other paramedicals working in the
Primary Health Centres are responsible for the distribution of iron tablets (adult
and paediatric doses) to the beneficiaries. The functionaries of ICDS programme
- such, as anganwadi worker (AWWs) assist in the distribution of iron tablets and
for imparting education to mothers on prevention of nutritional anaemia. Department
of Food (Ministry of Food and Civil Supplies) is responsible for promoting
consumption of iron rich foods. In addition, services of other community level
workers and involvement of formal and non-formal education, media, Horticulture
Departments and voluntary organizations is utilized for the effective implementation
of the programme. In addition, records of under fives and antenatal care maintained
under the material and child health services and ICDS programme, is used for
identifying beneficiaries as well as for recording and monitoring the distribution of
iron and folic acid supplements.
Under NIPI, all children aged 6 to 60 months, receive IFA supplements under the
direct supervision of ASHA worker on fixed days on a biweekly basis. ASHA
workers are also responsible for the doorstep distribution of IFA supplements to the
pregnant women and women in reproductive age group (WRA) on weekly house
basis.
We will now study the third nutrient deficiency programme i.e. National Iodine
Deficiency Disorders Control Programme (NIDDCP).
10.7.3 National Iodine Deficiency Disorders Control Programme

(NIDDCP)
You have read in Unit 3 that Iodine Deficiency Disorders (IDD) form a spectrum
of abnormalities which include goitre, mental retardation, deaf mutism, squint,
difficulties in standing or walking normally and stunting of the limbs. Iodine deficient
women frequently suffer abortions and still births. Their children may be born
deformed, mentally deficient or even cretins. All these problems are caused by
simple lack of iodine, and goitre is the least tragic of them. No State in India is
free from IDD. In India, out of the 239 districts surveyed (in 29 states and union
territories), 197 districts have goitre prevalence rates ranging from 10% to 65%.
Women in child-bearing age and children under the age of 15 years are most
susceptible to IDD. With every passing hour, 10 children are being born in India
who will not attain their optimum physical and mental potential due to iodine
deficiency. In 1962, the Government of India launched the National Goitre Control
Programme (NGCP), which aimed at controlling goitre by supplying and ensuring
consumption of iodized salt to the population living in the endemic region. The
224
Government re-structured the NGCP in 1986, and aimed at achieving the goal for Nutrition Policy and
Programmes
universal iodization of salt to control IDD in India by 1992. The National Goitre
Control Programme, referred to as the National Iodine Deficiency Disorders Control
Programme (NIDDCP) has now being revised in 2006. The revised NIDDCP aims
at universalizing iodisation of all edible salt. Let us now look at the objectives of
the NIDDCP.
Objectives
The objectives of the NIDDCP include:
1. Surveys to assess the magnitude of the Iodine Deficiency Disorder.
2. Supply of iodated salt in place of common salt.
3. Resurvey after every 5 years to assess the extent of iodine Deficiency
Disorders and the Impact of Iodated salt.
4. Laboratory monitoring of Iodated salt and urinary iodine excretion.
5. Health education and publicity.
The NFHS-4 (2015-16) surveyed the households for the presence of Iodine in their
salts. Among the households in which salt was tested, 93 percent had iodized salt,
much higher as reported in NFHS-3 where only 76 percent were using iodized salt.
Among the states, the use of iodized salt is lowest in Andhra Pradesh (82%), Tamil
Nadu (83%), and Dadra & Nagar Haveli (71%). Overall, the private sector
handles 94% of salt iodisation with the public sector handling a miniscule 6%. The
level of iodization has been fixed at 30ppm of iodine in salt at the manufacturing
level and 15ppm at the household level by the Goverment. To ensure exclusive use
of iodized salt in endemic areas, the sale of non iodized salt is being discouraged
nationally. Let us look at the target population for NIDDCP.
Target Group
Entire population, particularly women in child bearing age and young children.
Now, let us look at the implementation strategy.
Implementation strategy
The NIDDCP is executed by a multiplicity of agencies comprising the health,
Industry and Railway Ministeries of the Central Government. The Ministry of
Health and Family Welfare and Directorate General of Health Services (DGHS)
is responsible for the national implementation of the programme. The Salt Department,
under the Ministry of Industry, is the nodal agency for production, distribution,
monitoring and quality control of iodised salt. The Salt Commissioner, in consultation
with the Ministry of Railways, arranges for the movement of iodized salt from the
production center to the States. The State Government is responsible for the
distribution of the iodized salt within the state either through the Public Distribution
System or through the open market. For effective implementation of the NIDDCP,
a central IDD Cell is established at the DGHS level and is responsible for coordinating
surveys, training, monitoring and management of the IDD programme. All the
states/UTs have been advised to set up IDD Control Cell.
Thus, you saw that government has very well conceptualized and formulated
programmes to combat micronutrient deficiency in our country.
Now, let us check our learning by answering the questions included in the check
your progress exercise 4 given next.
225
Public Nutrition
1. List the various nutrient deficiency control programmes? Enumerate the
objectives of any one of the programmes.
...................................................................................................................
...................................................................................................................
...................................................................................................................
2. Explain the dietary actions you would take to promote foods rich in Vitamin
A.
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...................................................................................................................
...................................................................................................................
3. Mention the dosage of iron and folate, supplement for pregnant and preschool
children and dosage of vitamin A for infants and pre-schoolers.
...................................................................................................................
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.................................................................................................................
10.8 INFANT AND YOUNG CHILD NUTRITION

PROGRAMME (IYCN)
Since long, efforts have been carried out to implement optimal breastfeeding and
complementary feeding practices to achieve a healthy nutritional status among
infants and young children in our country. In this section we will learn two initiatives
specific to IYCN.
10.8.1 Infant and Young Child Feeding (IYCF) Guidlines

Recent times, after the adoption of the Global Strategy on Infant and Young Child
Feeding by the 55th World Health Assembly in May 2002, and adoption of the
Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production,
Supply and Distribution) Amendment Act, 2003 by the Parliament in June 2003,
National Guidelines on Infant and Young Child Feeding were formulated by the
Department of Women and Child Development. These guidelines are aimed at
creation of a movement among State Governments, district authorities, national
institutions and social organizations for achieving optimal infant and young child
feeding practices in the country. Let us look at the objectives of National Guidelines
on Infant and Young Child Feeding (IYCF).
The objectives of the National Guidelines on IYCF are:
 to advocate the cause of infant and young child nutrition and its improvement
through optimal feeding practices nationwide
 to disseminate widely the correct norms of breastfeeding and complementary
feeding from policy making level to the public at large in different parts of the
country in regional languages
226
 to help plan efforts for raising awareness and increasing commitment of the Nutrition Policy and
Programmes
concerned sectors of the Government, national organizations and professional
groups for achieving optimal feeding practices for infants and young children
 to achieve the national goals for Infant and Young Child Feeding practices so
as to achieve reduction in malnutrition levels in children
A summary of the norms defined under the IYCF guidelines are presented in the
Box 1.
Box 1 Norms for Infant and Young Child Feeding
 Initiation of breastfeeding immediately after birth, preferably within one hour.
 Exclusive breastfeeding for the first six months i.e., the infants receives only
breast milk and nothing else, no other milk, food, drink or water.
 Mother should communicate, look into the eyes, touch and cares the baby
while feeding.
 Appropriate and adequate complementary feeding from six months of age

while continuing breastfeeding.
 Continued breastfeeding up to the age of two years or beyond.
 WHO growth charts recommended for monitoring growth.
Some of the important strategies of appropriate infant and young child feeding
practices are highlighted herewith:
a) Breastfeeding:
 Breastfeeding (BF) should be promoted as the gold standard feeding
options.
b) Complementary nutrition:
 Appropriately thick homogenous complementary foods home-made from
locally available foods should be introduced at six completed months
 Each meal must be made energy dense by adding sugar / jaggery and
ghee/butter/oil.
 Adequate total energy intake should be ensured by addition of one to two
nutritious snacks between the three main meals.
 Consistency of foods should be appropriate to the developmental readiness
of the child in munching, chewing and swallowing.
 Easily available, cost-effective seasonal uncooked fruits, green and other
dark colored vegetables, milk and milk products, pulses/ legumes, animal
foods, oil/ butter, sugar/ jaggery may be added in the staples gradually.
 Foods can be enriched by making a fermented porridge, use of germinated
or sprouted flour and toasting of grains before grinding. The details of
food including; texture, frequency and average amount are summarized
in Table 10. 5.
 Hygienic practices are essential for food safety during all the involved
steps viz. preparation, storage and feeding.
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Public Nutrition
Table 10.5: Amounts of foods to offer to an infant and young child
Age Texture Frequency Average Amount

Each Meal
6-8 months Start with thick 2-3 meals per day Start with 2-3
porridge, well plus frequent BF tablespoon full
mashed foods
9-11 months Finely chopped or 3-4 meals plus ½ of a 250 ml
mashed foods, and BF. Depending on cup/bowl
food stuff that baby appetite offer 1-2
can pick up snacks
12-23 months Family foods, 3-4 meals plus BF. ¾ to one 250 ml
chopped or mashed Depending on cup/bowl
if necessary appetite offer
1-2 snacks
Some of the key recommendations related to infant and young child feeding are
summarized in Box 2.
Box 2 Key Messages Related to Infant and Young Child nutrition
 Initiation of breastfeeding as early as possible after birth, preferably within

one hour
 Exclusive breastfeeding in the first six months of life and no other foods
or fluids.
 Appropriate and adequate complementary feeding after completion of six

months. Complementary foods should not be confused with supplementary
foods.
 Hand washing with soap and water at critical times– including before
eating or preparing food and after using the toilet.
 Avoid junk food. Home food should be preferred over artificial, commercial,
tinned or packaged food.
 Promote and establish Human Milk Banks.
 Full immunization and Vitamin-A supplementation with deworming.
 Effective home based care and treatment of children suffering from severe
acute malnutrition.
 Adequate nutrition and anaemia control for adolescent girls, pregnant and
lactating mothers.
 Effective implementation and monitoring of IMS Act and other laws related
to child nutrition.
10.8.2 Maternal Absolute Affection (MAA)

A nationwide programme named MAA was launched on 5th August, 2016, in an
attempt to bring undiluted focus on promotion of breastfeeding, in addition to the
ongoing efforts through the health system. The goal of the MAA programme is to
revitalize efforts towards promotion, protection and support of breastfeeding practices
through health systems to achieve higher breastfeeding rates. Let us look at the
228 objectives of the MAA programme.
The following are the objectives of the programme in order to achieve the above Nutrition Policy and
Programmes
mentioned goals:
1. Build an enabling environment for breastfeeding through awareness generation
activities, targeting pregnant and lactating mothers, family members and society
in order to promote optimal breastfeeding practices. Breastfeeding, to be
positioned as a important intervention for child survival and development.
2. Reinforce lactation support services at public health facilities through trained
healthcare providers and through skilled community health workers.
3. To incentivize and recognize those health facilities that show high rates of
breastfeeding along with processes in place for lactation management.
Components of MAA programme include:
 Awareness generation  Building and enabling environment and demand
generation through mass media, mid media and community.
 Community level activitiesCapacity building of community health workers-
ASHAs, AWWs , ANM’s on breastfeeding and community dialogue through
mothers’ meeting conducted by ASHA. Trained ANMs at sub-centres for
providing skilled care in the communities.
 Health facility strengthening  Capacity building of ANMs/nurses/doctors
– at all delivery points. Role re-enforcement regarding lactation support services.
 Monitoring  Recognition for best performing baby friendly facilities.
1. Enumerate the Norms for Infant and Young Child Feeding.
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10.9 NATIONAL HEALTH MISSION (NHM)

The National Health Mission (NHM) was launched in 2013 subsuming the National
Urban Health Mission to provide quality health services. The Mission adopts a
synergistic approach by relating health to determinants of good health viz. segments
of nutrition, education, society and gender equality, sanitation, hygiene and safe
drinking water. NHM is proposed to cover the entire country with special focus on
18 States including 8 Empowered Action Group (EAG) (Bihar, Chhattisgarh,
Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttaranchal and Uttar Pradesh),
identified to have weak public health indicators and /or weak health infrastructure.
The major goals of NHM can be enlisted as:
 To reduce MMR to 1/1000 live births
 To reduce IMR to 25/1000 live births
 To reduce TFR to 2.1
 Prevention and reduction of anaemia in women aged 15–49 years,
 Prevent and reduce mortality & morbidity from communicable, non-
communicable; injuries and emerging diseases, 229
Public Nutrition  Reduce household out-of-pocket expenditure on total health care expenditure
 Reduce annual incidence and mortality from Tuberculosis by half 8
 Reduce prevalence of Leprosy toreduce prevalence of Leprosy to <1/
10000 population and incidence to zero in all districts
 Annual Malaria Incidence to be <1/1000
 Less than 1 per cent microfilaria prevalence in all districts
 Kala-azar Elimination by <1 case per 10000 population in all blocks
Some of the major initiatives under National Health Mission (NHM) are as follows:
Accredited Social Health Activists
Community Health volunteers called Accredited Social Health Activists
(ASHAs) have been engaged under the mission for establishing a link between
the community and the health system. ASHA is the first port of call for any
health related demands of deprived sections of the population, especially women
and children, who find it difficult to access health services in rural areas.
ASHA Programme has increased the utilization of outpatient services, diagnostic
facilities, institutional deliveries and inpatient care.
Untied Grants to Sub-Centres
Untied Grants to Sub-Centers have been used to fund grass-root improvements
in health care. Some examples include:
 Improved efficacy of Auxiliary Nurse Midwives (ANMs) in the field that
can now undertake better antenatal care and other health care services.
 Village Health Sanitation and Nutrition Committees (VHSNC) have used
untied grants to increase their involvement in their local communities to
address the needs of poor households and children.
National Iron + Initiative (NIPI)
The National Iron + Initiative is an attempt to look at Iron Deficiency Anaemia
in which beneficiaries receive iron and folic acid supplementation irrespective
of their Iron/Hb status. This initiative work with existing programmes (IFA
supplementation for: pregnant and lactating women, and; children in the age
group of 6–60 months) and introduced new age groups as given in Table 10.3
under section 10.7.2.
Various programmes related to women and children health have also been
included under the NHM. These programmes are briefly discussed here:
10.9.1 Reproductive, Maternal, New-born, Child and Adolescent
Health Programme (RMNCH+A)
This is a comprehensive programme for improving the maternal and child health
under National Health Mission (NHM). Earlier programme naming Reproductive
and Child Health (RCH 1) launched in 1997-98, targeted only two components
i.e. women and children. Later, it was realized that reproductive, maternal and
child health cannot be addressed in isolation as these are closely linked to the
health status of the population in various stages of life cycle importantly
adolescents. Therefore, a new programme called Reproductive, Maternal, New-
born, Child and Adolescent Health (RMNCH+A) was formulated in 2013, which
includes integrated service delivery in various life stages i.e. adolescence, pre-
pregnancy, childbirth and postnatal period, childhood and through reproductive
age. Some of the major goals and components established during initiation of
230 the programmes are listed below:
Goals established in the 12th Five Year Plan Nutrition Policy and
Programmes
 Reduction of Infant Mortality Rate (IMR) to 25 per 1,000 live births by 2017
 Reduction in Maternal Mortality Ratio (MMR) to 100 per 100,000 live births
by 2017
 Reduction in Total Fertility Rate (TFR) to 2.1 by 2017
Components of health care under RMNCH+A includes:
For Adolescents and women in reproductive age health care
 Adolescent nutrition, iron and folic acid supplementation
 Facility-based adolescent reproductive and sexual health services (Adolescent
health clinics)
 Information and counsellling on adolescent sexual reproductive health and
other health issues
 Menstrual hygiene and preventive health checkups.
 Prevention and management of sexually transmitted and reproductive infections
(STI/RTI)
 Comprehensive abortion care (includes MTP Act)
 Community-based promotion and delivery of contraceptives
For maternal and child health care
 Immediate essential newborn care and resuscitation
 Delivery of antenatal care package and tracking of high-risk pregnancies
 Postpartum care for mother and newborn
 Home-based newborn care and prompt referral
 Facility-based care of the sick newborn
 Integrated management of common childhood illnesses (diarrhoea, pneumonia
and malaria)
 Child nutrition and essential micronutrients supplementation (IFA, Vitamin A)
 Immunizations
 Early detection and management of defects at birth, deficiencies, diseases and
disability in children (0–18 years)
Let us move on to the next pogramme which is initiated for the adolescents i.e.
Rashtriya Kishor Swasthya Karyakram.
10.9.2 Rashtriya Kishor Swasthya Karyakram (RKSK)
In order to ensure holistic development of adolescent population, the Ministry of
Health and Family Welfare launched Rashtriya Kishor Swasthya Karyakram
(RKSK) on 7 th January 2014, to reach out to 253 million adolescents - male and
female, rural and urban, married and unmarried, in and out-of-school adolescents with
special focus on marginalized and undeserved groups. The programme expands the
scope of adolescent health programming in India - from being limited to sexual and
reproductive health to ambit nutrition, injuries and violence (including gender based
violence), non-communicable diseases, mental health and substance misuse. The strength
of the program is its health promotion approach. It is a paradigm shift from the existing
clinic-based services to promotion and prevention and reaching adolescents in their
own environment, such as in schools, families and communities. 231
Public Nutrition As a part of the scheme, promotion of menstrual hygiene among adolescent girls
in the age group of 10-19 years primarily in rural areas has also been initiated.
Under the scheme, knowledge about menstrual hygiene, access and use of good
quality sanitary napkins and safe disposal of sanitary napkins, are being provided.
Also, there is a provision for providing sanitary napkins packs at subsidized rate
(Rs 1/napkin, Rs 6 for a pack of 6 napkins) to the rural adolescent girls by the
ASHA workers on monthly basis.
Additionally, weekly Iron-Folic acid Supplementation (WIFS) programme for school
going adolescent is being scaled up in the entire country. WIFS programme offers
an opportunity for imparting education on self and family care to adolescent girls.
The iron supplementation (100 mg elemental iron and 500 mcg folic acid using a
fixed day approach) is to be administered to adolescent of 6th to 12th class (boys
and girls aged 10 to 19 years) through school health programme. Biannual deworming
(Albendozole 400 mg) is also provided for control of helminthic infestation.
10.9.3 Janani Suraksha Yojna (JSY)

JananiSurakshaYojna was proposed under NRHM by modifying the existing National
Maternity Benefit Scheme (NMBS). Earlier the scheme provide cash assistance
to pregnant women from Below Poverty Line (BPL) families for better diet. While
under JSY cash assistance is linked to antental care during pregnancy, institutional
care during delivery and immediate post-partum period in a health centre. This is
coordinated by a village level health worker. JSY is a 100% centrally sponsored
scheme.
 To reduce maternal mortality ratio and infant mortality rate.
 To increase institutional deliveries among BPL families.
10.9.4 Janani Shishu Suraksha Karyakram (JSSK)

It was launched on 1st June 2011 to assure free service to all pregnant women and
sick neonate accessing public health institution. The scheme envisage free and
cashless servces to pregnant women including normal deliveries and caesarean
operations and also tratment of sick newborn (up to 30 days after birth) in all
government health institutions across all State/UTs. Entitlements would include free
drugs and consumables, free diagnostics, free blood whereever required, and free
diet for the duration of a women’s stay in the facility, expected to be three days
in case of normal delivery and seven in case of a caesarean section. Similar
entitlements have been put in place for all sick newborns. They would also be
entitled to free treatment besides free transport, both ways and between facilities
in case of a referral.
With this we end our study about NHM. Now, let us check your learning by
answering the quesions given in the check your progress excercise 6.
1. Enumerate the goals/objective of NHM.
....................................................................................................................
....................................................................................................................
....................................................................................................................
2. What are the components of child health care under RMNCH+A
....................................................................................................................
....................................................................................................................
232 ....................................................................................................................
3. What are the main goals of Janani Suraksha Yojna (JSY). Programmes
....................................................................................................................
....................................................................................................................
....................................................................................................................
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10.10 FOOD SECURITY PROGRAMMES

Food security as you may recall studying in Unit 2 refers to access by all people
at all times to enough food for an active and healthy life. It is now well recognised
that the availability of food grains is not a sufficient condition to ensure food
security to the poor. It is also necessary that the poor have sufficient means to
purchase food. The capacity of the poor to purchase food can be ensured in two
ways – by raising the incomes or supplying food grains at subsidized prices. While
employment generation programmes attempt the first solution, the public distribution
system (PDS) is the mechanism for the second option. Our government has made
consistent efforts to improve availability of food for poor. Besides the PDS, other
programmes such as, the Antyodaya Anna Yojna (AAY), the Annapurna Scheme,
National Food for Work Programme (NFFW) has also been launched. Let us learn
about these programmes, here in this section. We shall begin with the PDS and
TPDS.
10.10.1 Public Distribution System (PDS) and the Targeted Public

A well targeted and properly functioning Public Distribution System (PDS) is an
important constituent of the strategy for poverty alleviation. PDS continues to be
a major instrument of Government’s economic policy for ensuring food security to
the poor. With a network of more than 4.62 lakh fair price shops (FPS) distributing
commodities worth more than Rs 30,000 crore annually to about 160 million families,
the PDS in India is perhaps the largest distribution network of its kind in the world.
For effective functioning of PDS, the Central Government bears the responsibility
for procurement and supply of foodgrains namely, wheat and rice, besides sugar,
imported edible oils and kerosene to the State governments and the Union Territories
for distribution. Some States /UTs distribute additional items of mass consumption
also through the PDS outlets.
The PDS as it was being implemented earlier, had been widely criticized for its
failure to serve the population Below the Poverty Line (BPL), its urban bias,
limited coverage in the States with high concentration of the rural poor and lack
of transparent and accountable arrangements for delivery. Therefore, in June
1997, the Government of India launched the Targeted Public Distribution System
(TPDS) with aim to provide subsidized food and fuel to the poor through a network
of ration shops. On December, 2012, National Food Security Act, 2013 was launched.
The Act provided statutory backing for improving TPDS.
Under the new system a two tier subsidized pricing system has been introduced
to benefit the poor. The essential features of TPDS are: Government of India is
committed to provide available foodgrains to the States to meet the requirement of
foodgrains at the scale of 10 Kg per month per family at specially subsidized prices
to population falling below the officially estimated poverty line (BPL families). The
states would also receive the quantity needed for transitory allocation to Above
Poverty Line (APL) population. The state governments to streamlined the PDS by
issuing special cards to BPL families and selling essential articles under TPDS at
specially subsidized prices, with better monitoring of the delivery system.
233
Public Nutrition The BPL households were determined on the basis of population projections of
the Registrar General of India for 1995 and the State wise poverty estimates
(1993-94) of the Planning Commission for 1993-94. In 2013, 4.09 crore BPL
families and 11.52 crore APL families were entitled for the subsidized food grains
such as wheat and rice. Also states have the discretion to provide other commodities
like sugar, kerosine and fortified atta under TPDS.
Keeping in view, the consensus on increasing the allocation of foodgrains to BPL
families, and to better target the food subsidy, Government of India increased the
allocation to BPL families from 10 Kg to 35 Kg of foodgrains per family per
month. The allocation of APL families has also been revised and increased from
15 to 35 kg of food grain per family.
The end retail price is fixed by the States/UTs after taking into account margins
for wholesalers/retailers, transportations charges, levies, local taxes etc. Under the
TPDS the States are requested to issue food grains at a difference of not more
than 50 paise per Kg over and above the Central Issue Price (CIP) for BPL
families. Flexibility to States/UTs. has been given in the matter of fixing the retail
issue prices by removing the restriction of 50 paise per Kg over and above the CIP
for distribution of foodgrains under TPDS except with respect to Antyodaya Anna
Yojana (AAY) where the end retail price is to be retained at Rs. 2/- Kg. for wheat
and Rs. 3/- Kg. for rice. We shall learn about the AAY scheme in a little while
from now.
For identification of BPL families under TPDS, Gram Panchayats and Nagar
Palikas are involved. While doing so the thrust is to include the really poor and
vulnerable sections of the society such as landless agricultural labourers, marginal
farmers, rural artisans/craftsmen such as potters, tapers, weavers, black-smith,
carpenters etc. in the rural areas and slum dwellers and persons earning their
livelihood on daily basis in the informal sector like potters, rickshaw-pullers, cart-
pullers, fruit and flower sellers on the pavement etc. in urban areas.
Scale and Issue Price
The scale of issue under APL, BPL and AAY has been revised to 35Kg per family
per month with effect from 1.4.2002 with a view to enhancing the food security
at the household level
10.10.2 Antyodaya Anna Yojana (AAY)
Antyodaya Anna yojana has been launched by the Hon’ble Prime Minister of
India on the 25th December, 2000. This scheme reflects the commitment of
the Government of India to ensure food security for all and create a hunger free
India in the next five years and to reform and improve the Public Distribution
System so as to serve the poorest of the poor in rural and urban areas. It is for
the poorest of poor that the Antyodya AnnaYojana has been conserved. It is
estimated that 5% of population are unable to get two square meals a day on a
sustained basis through out the year. Their purchasing power is so low that they
are not in a position to buy food grains round the year even at BPL rates. It is this
5% of out population (5 crores of people or 1 crore families) which constitutes
the target group of Antyodaya Anna Yojana.
Scale and Issue Price
Antyodaya Anna Yojana contemplates identification of one crore families out of the
BPL families who would be provided food grains at the rate of 35 Kg per family
per month. The food grains are issued by the Government of India @ Rs.2/- per
Kg for wheat and Rs. 3/- per Kg for rice. The Government of India suggests that
in view of abject poverty of this group of beneficiaries, the State Government may
234 ensure that the end retail price is retained at Rs.2/-per Kg for wheat and Rs.3/-
per Kg for rice and Rs. 1 for course grain. AAY families can also buy 1 kg of Nutrition Policy and
Programmes
sugar at a rate of 18.50 / kg via ration shops.
Identification of Beneficiaries
The most crucial element for ensuring the success of AAY is the correct identification
of Antyodaya families. It is estimated that there are 4.09 crore families below
poverty line in the country as on year 2013. These families are being provided food
grains under the TPDS at highly subsidised rates. One croreAntyodaya families
would constitute about 15.33% of the BPL families in the country. The identification
of these families are carried out by the State Government / UT administrations,
from amongst the number of BPL families within the state.
Issue of Ration Cards
After the identification of Antyodaya families, distinctive ration cards to be known
a “Antyodaya Ration Card” are issued to the Antyodaya families by the designated
authority. The ration card have the necessary details about the Antyodaya family,
scale of ration etc.
In the Union Budget 2005-06, the AAY has been expanded to cover 50 lakh BPL
households. As on 30.04.2009, 242.75 lakh AAY families have been covered by the
States/UTs.
Finally, let us get to know about the Annapurna Scheme.
10.10.3 Annapurna Scheme

The Annapurna scheme aims at providing food security to meet the requirement
of those Senior Citizens who though eligible have remained uncovered under the
National Old Age Pension Scheme (NOAPS). Under the Annapurna Scheme, 10
Kg of food grains per month are to be provided ‘free of cost’ to the beneficiary.
The number of persons to be benefited from the Scheme will, in the first instance,
be 20% of the persons eligible to receive pension under NOAPS in States/Union
Territories. The National Old Age Pension Scheme (NOAPS), launched in 1995,
seeks to provide pension from Rs. 250 to 1500 depending on the different states.
As per the data of 2014-15 the number of beneficies under this scheme are
928333.
Who are eligible for this scheme and how are they identified? Let’s find out next.
Eligibility Criteria
Central assistance under Annapurna Scheme is provided to the beneficiaries fulfilling
the following criteria:
a. The age of the beneficiary (male or Female) should be 65 years or above.
b. The benificiary must be “destitute” in the sense of having little or no
regularmeansof subsistence from his/her own source of income or through
financial support from family members or other sources. In order to determine
destitution, the criteria (if any) currently in force in the State/UTs could also
be followed.
c. The beneficiary should not be in recipient of pension under the NOAPS or
State Pension Scheme.
d. The beneficiery should not be AAY/BPL category ration card holder.
Identification of Beneficiaries
a. The Gram Panchayat is required to identify, prepare and display list of persons
eligible to receive benefits under the annapurna Scheme, after giving wide
235
Public Nutrition publicity to the Scheme. The Panchayat is also responsible for the distribution
of the Entitlement Card to beneficiaries, the dissemination of information
about theScheme and the procedure for securing benefits under the same.
The Municipality is responsible for the above activities in the implementation
of the scheme in their respective areas. The State Government communicates
the targets for “Annapurna” to the Panchayat and municipalities for identification
of the beneficiaries.
Next, who is responsible for implementation of this scheme? The following paragraph
highlights this aspect.
Implementing Authorities
a. The Department of Public Distribution, Union Ministry of Consumer Affairs

and Public Distribution ensures the supply of required quantities of prescribed
quality food grains from the godowns of the Food Corporation of India (FCI)
to the agency designated by the State Government.
b. At the State level, the State Department of Public Distribution (Departments

of Food, Civil Supplies and Consumer Affairs) and at the District level, the
Collector/District Magistrate/Chief Executive Officer, Zila Panchayat is squarely
responsible for the implementation of the scheme. The state Food, Civil Supplies
and Consumer Affairs Department will purchase the food grains from the
Food Corporation of India on payment of economic cost and will ensure that
the FCI supplies the food grains to the district as per district-wise allocation
decided by the state within the overall allocation of the State concerned. The
Collector/CEO, through the District Officers of the State Food, Civil Supplies
and Consumer Affairs Department is responsible for ensuring the availability
of food grains atthe District level and for distributing the same through the
Network of Fair Price Shops under the Targeted Public Distribution System
(TPDS). The Collector/CEO makes arrangement for the distribution of food
grains and issue the Entitlement Cards through the Panchayat/Municipalities
and ensurethatthe beneficiaries covered under Annapurna are not receiving
any old age pensions.
10.10.4 National Food for Work Programme (NFFWP)

The National Food for Work Programme has been conceived with the objective to
provide additional resources apart from the resources available under the Sampoorna
Grameen Rozgar Yojana (SGRY) (about which we shall study in the next section)
to 150 most backward districts of the country so that generation of supplementary
wage employment and providing of food-security through creation of need based
economic, social and community assets in these districts is further intensified. The
NFFWP is open to all rural poor who are in need of wage employment and desire
to do manual and unskilled work. The programme is self-targeting in nature.
Distribution of foodgrains as part of wages under the NFFWP is the focus of the
programme and based on the principle of protecting the real wages of the workers
besides improving the nutritional standards of the families of the rural poor. Under
the scheme, foodgrains are given as part of wages to the rural poor at the rate of
5 Kg per man per day. More than 5 kg foodgrains can be given to the labourers
under this programme in exceptional cases subject to a minimum of 25% of wages
to be paid in cash. The State Governments will take into account the cost of
foodgrains paid as part of wages, at a uniform BPL rate. The workers will be paid
the balance of wages in cash, such that they are assured of the notified Minimum
236 Wages.
The programme initially covered 150 most backward districts of the country and Nutrition Policy and
provided additional supplementary wage employment through creation of need- Programmes
based economic, social and community assets. Works relating to water conservation,
drought proofing and land improvement, flood control and rural connectivity of all-
weather roads are taken up to create wage employment. The Centre provides food
grains and cash component to the states to generate additional wage employment.
Distribution of foodgrains to the workers under the programme is either through
PDS or by the Village Panchayat or implementing agency or any other Agency
appointed by the State Government. Distribution of foodgrains is made to the
workers, most preferably, at the work site. Now, the programme has been subsumed
with the NREGA, about which you will learn under the section 10.11.
With this we end our study about the programmes being run by the government to
ensure adequate availability of foodstuffs for the poor. In addition to the programmes
discussed above there are a few employment schemes linked with food security.
We will review a few of these next.
10.11 SELF EMPLOYMENT AND WAGE

EMPLOYMENT SCHEMES
Poverty alleviation and employment generation programmes have been in operation
for several years. The specifically designed anti-poverty programmes for generation
of self employment and wage employment in rural areas have been redesigned and
restructured to improve their efficacy/impact on the poor and ensuring food security.
Some of these programmes are discussed in this section.
10.11.1 Sampoorna Gramin Rojgar Yojana (SGRY)
The Sampoorna Gramin Rojgar Yojana (SGRY) was launched by the Government
of India on 1st September, 2001 to attain the objective of providing gainful
employment for the rural poor. The Yojana was started merging the provisions of
Employment Assurance Scheme (EAS) and Jawahar Gram Samridhi Yojana
(JGSY). The scheme has provision for women, scheduled castes, scheduled tribes
and parents of children from hazardous occupations, while preference is given to
the families under BPL. The scheme is self targeting in nature. Under the scheme
the food grains are distributed to the labourers as a part of wages at the BPL rate.
The main objective of the scheme is to give the security to the rural poor and
create a water conservation/watersheds, roads and small infrastructures by generating
the employment for poverty alliviation through the employment and foodgrains.
Generation of supplementary employment for the unemployment poor in the rural
area is the focus of the scheme.
The SGRY is available for all the rural poor (BPL and APL), who are in need of
wage employment and are willing to take up manual on unskilled works in an
around his/her village and habitation. The programme is implemented as a Centrally
Sponsored Scheme on cost sharing basis between the Central and State in the ratio
of 75:25.
Next, we move on to the Swarna jayanti Gram SwarozgarYojna.
10.11.2 Swarnajayanthi Gram Swarozgar Yojana (SGSY)
The initial Scheme Swarnajayanti Swarozgar Yojana (SGSY) was launched in
1999, which was renamed as National Rural Livelihood Mission (NRLM) in 2011,
and then finally merged by Deen Dayal Antyodya Yojana (NRLM-DAY) in November,
2015.
The yojana aims at reducing urban poverty by improving livelihood opportunities
through skill training and skill upgradation for self-employment, subsidized bank
237
Public Nutrition loans for setting up micro-enterprises, organising urban poor into self-help groups,
among others.
The objective of DAY is skill development of both urban and rural India as per
requisite international standards. Since the inception (2014 to 2018) skills has been
imparted to 4.54 lakh urban poor, giving employment to one lakh (22%) such
people.
DAY-NRLM integrates various agencies - District Rural Development Agencies,
banks, line departments, Panchayati Raj Institutions, Non-Governmental Organizations
(NGOs) and other semi-government organizations.
10.11.3 National Rural Employment Guarantee Act 2005
(NREGA)
NREGA was started in 2006, renamed as the “Mahatma Gandhi National Rural
Employment Guarantee Act” (or, MGNREGA), is an Indian labour law and social
security measure that aims to guarantee the ‘right to work’. It aims to enhance
livelihood security in rural areas by providing at least 100 days of wage employment
in a financial year to every household whose adult members volunteer to do
unskilled manual work. NREGA was started in 2006, renamed as the Mahatma
Gandhi National Rural Employment Guarantee Act (or, MGNREGA), is an Indian
labour law and social security measure that aims to guarantee the ‘right to work’.
It aims to enhance livelihood security in rural areas by providing at least 100 days
of wage employment in a financial year to every household whose adult members
volunteer to do unskilled manual work.
It is “the largest and most ambitious social security and public works programme
in the world”. The main objective of MGNREGA is to “enhancing livelihood
security in rural areas by providing at least 100 days of guaranteed wage employment
in a financial year, to every household whose adult members volunteer to do
unskilled manual work” and to create durable assets (such as roads, canals, ponds,
wells).
With this we end our study of the food security and the wage employments
schemes. Do answer the check your progress exercise given herewith. This will
help you recapitulate what you have learnt so far.
a. ………. is the main food subsidy programmes implemented by the
government to provide food security to poor people in India.
b. ………. and …… are the local bodies involved in the identification of
BPL families.
c. …. Yojana launched on 25the December, 2000 serves the poorest of
the poor in rural and urban area.
d. Distribution of food grains is done as a part of wages under the
programme ……..
e. The implementing authority of Annapurna Scheme at the state level is
………… of public distribution.
2. Why were the Food Security Programme sinitiated. List the various Food
Security programmes initiated in our country?
...................................................................................................................
...................................................................................................................
...................................................................................................................
238
3. Enumerate the working of the PDS. Also mention the highlights of TPDS. Nutrition Policy and
Programmes
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
4. Who are the beneficiaries of Annapurna Scheme? Discuss the criteria for
being eligible for this scheme.
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
5. List the salient features of National Food for Work Programme.
...................................................................................................................
...................................................................................................................
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...................................................................................................................
...................................................................................................................
10.12 LET US SUM UP

In this unit we studied that the Government of India has undertaken several measures
in alleviating the problems of malnutrition in the country. Some of these include
formulation and implementation of National Nutrition Policy and various nutrition
intervention programmes like Integrated Child Development Services Scheme,
nutrient deficiency control programmes and supplementary feeding programmes.
The National Nutrition Policy advocates a “comprehensive, integrated and inter-
sectoral strategy for alleviating the multifaceted problem of malnutrition and achieving
the optimal state of nutrition for the people”. The Integrated Child Development
Services is the world’s most unique welfare programme, which holistically addresses
health, nutrition and development needs of young children, adolescent girls and
pregnant/nursing mothers across the life cycle. The three important ongoing Nutrient
deficiency control programmes are: 1) National Prophylaxis Programme for
Prevention of Blindness due to Vitamin A deficiency 2) National Nutritional Anaemia
Control Programme, and 3) National Iodine Deficiency Disorder (IDD) Control
Programme. These programmes aim towards reduction/elimination of vitamin A
deficiency, iron deficiency anemia and iodine deficiency disorders respectively. Mid
Day Meal Programme is one of the most important ongoing supplementary feeding
programmes organized by the Department of Education. It is aimed at not only to
improve the nutritional status of school children but also to attract poor children to
school. In addition to these progtrammes the programmes linked to food security
and wage employment such as PDS, food for work programme, SGRY and DAY
were alco described.
239
Public Nutrition
10.13 GLOSSARY
Intrauterine device : A birth control device, such as a plastic or metallic
loop, ring, or spiral, that is inserted into the uterus to
prevent implantation.
Mahilamandal : Women’s group formed to carry out specific activities

EXCERCISES
1. The main aims of the NNP are:

 The draw attention to the urgent need to reduce malnutrition in the
country.
 To highlight the need for inter-sectoral coordination to achieve nutritional
goals.
 To orient relevant sectors to perceive nutrition as an outcome of their
sectoral activities, and
 To identify short term, intermediate and long-term strategies for achieving

nutritional goals either through direct policy changes or indirect institutional
or structural changes.
2. The two direct short-term interventions of Nutrition Policy Instruments are.
a. Fortification of essential foods, for example salt with iodine and / or iron.
b. Production and popularization of low cost nutritions foods from indigenous

and locally available raw material, by involving women in this activity.
The two indirect policy instruments of Nutrition policy are:
i. Ensuring food security, a per capita availability of 215Kg/ person/ year

of food grains
ii. Improvement in the dietary patterns by promoting the production and

increasing the per capita availability of nutritionally rich foods.
3. The nodal responsibility at the central level for policy implementation rests
with the Ministry of Human Resource Development under the chairmanship
of Secretary, Department of Women and Child Development. Sectoral
Ministries/ Departments concerned like Agriculture, Food, Civil Supplies, Health
and Family Welfare, Rural Development, Education and Environment, who
role is crucial for sustainable improvement in nutritional status of the population,
are represented on the Inter-Ministerial Coordination Committee. A National
Nutrition Council is constituted in the Planning Commission with the Prime
Minister as is President and concerned Union Ministers, a few State Ministers
by rotation, and experts, representatives of non-governmental organizations
and grass root leaders especially women) as its members. Further, the effective
implementation of the NNP is dependent to a large extent on the State
Governments/ Union Territory Administration and the constitution of State
Nutrition Councils.
240
Check Your Progress Exercise 2 Nutrition Policy and
Programmes
1. The various nutrition programmes include: Integrated Child Development

Services Programme (ICDS), Nutrient Deficiency Control Programmes namely
National Prophylaxis Programme for Prevention of Blindness due to Vitamin
A deficiency, National Nutritional Anaemia Control Programme, National Iodine
Deficiency Disorder (IDD) Control Programme, Food Supplementation
Programmes like the Special Nutrition Programme (SNP), Balwadi Feeding
Programme, Composite Nutrition Programme and Applied Nutrition
Programmes. Food Security Programmes, namely Public Distribution System
(PDS), Antodaya Anna Yojna, Annapurna Scheme, National Food for Work
programme and the Self Employment Programmes, linked to Food security
namely Swaranjayanti Gram Swarozgar Yogana, Sampoorna Gramin Rojgar
Yogana.
2. The major objectives of ICDS are:
- To improve the nutritional and health status of children in the age

group 0-6 years and adolescents.
- Lay the foundation for proper psychological physical and social

development of the child.
- Reduce the incidence of mortality, morbidity, malnutrition and school

drop-out.
- Achieve effective coordination of policy and implementation amongst the

various departments to promote child development.
- Enhance the capability of the mother to look after the health and nutritional
needs of the child through proper nutrition and health education.
3. Programme components of ICDS’s scheme are supplement Nutrition,

immunization,periodic health and check-ups, treatment of minor ailments and
referral services, growth monitoring, non-formal pre-school education, health
andnutrition education, adolescent girls scheme, safe drinking water.
4. Objectives of PMMVY
To improve the health and nutrition status of Pregnant and Lactating (P & L)
women and their young infants by:
 Promoting appropriate practices, care and service utilization during

pregnancy, safe delivery and lactation.
 Encouraging women to follow (optimal) Infant and Young Child Feeding

(IYCF) practices including early and exclusive breastfeeding for the first
six months.
 Contributing to better enabling environment by providing cash incentives

for improved health and nutrition to pregnant and lactating women.

1. a) True
b) False. The MDM programme is operated by department of education
c) True
241
Public Nutrition 2. The major components of the MDM programme in food supplementation, this
consists of:
— 100/150 g of food grains (wheat or rice) per child per school day where
cooked meals are served; 3/4.5 kgs food grains per student per month
where food grains are distributed.
— Transport subsidy up to maximum Rs.75 per quintal for movement of
food grains from the nearest FCI depot to schools.
— Food grains (wheat/rice) is supplied through FCI the cost of which is
reimbursed at BPL.
1. The various nutrient deficiency control programmes are:
a. National Prophylaxis Programme for Prevention of Blindness due to
vitamin A deficiency.
b. National Nutritional Anaemia Control Programme.
c. National Iodine deficiency Disorders Control Programme (NIDDCP).
The objectives of NIDDCP are:
The objectives of the NIDDCP include:
 Surveys to assess the magnitude of the Iodine Deficiency Disorder.
 Supply of iodated salt in place of common salt.
 Resurvey after every 5 years to assess the extent of iodine Deficiency
Disorders and the Impact of Iodated salt.
 Laboratory monitoring of Iodated salt and urinary iodine excretion.
 Health education and publicity.
2. Various dietary actions one would take to promote foods rich in iron include:
 Regular dietary intake of vitamin A rich foods by pregnant and lactating
mothers and by children under 5 years of age must be promoted
 The mothers attending antenatal clinics and immunization sessions, as
well as mothers and children enrolled in the ICDS Programme must be
made aware of the importance of preventing vitamin A deficiency
 Breastfeeding including feeding of colostrums must be encouraged
 Feeding of locally available B-carotene (precursor of vitamin A) rich
food such as green leafy vegetables and yellow and orange vegetables
and fruits like pumpkin, carrots, papaya, mango, oranges etc. along with
cereals and pulses to a weaning child must be promoted widely. In
addition, whenever, economically feasible, consumption of milk, cheese,
paneer, yoghurt, ghee, eggs, liver etc. must be promoted.
3. Dosage recommended for pregnant and preschool children for iron are
as follows:
a. Pregnant Women: One big (adult) tablet per day for 100 days (each
tablet containing 60 mg/100 mg of elemental iron of 500 mcg folate, in
the first trimester of pregnancy.
b. Preschool Children (1-5 years): One paediatric (small) tablet containing
20mg iron and 100 mcg folic acid daily for 100 days every year.
242
The recommended dosage of vitamin A for the pregnant and pre- Nutrition Policy and
Programmes
school childrenis:
a. Infants (6-11 months): one dose of 100000IU every 6 months
b. Preschool children: a dose of 200000IU every 6 months
Norms for Infant and Young Child Feeding:
 Initiation of breastfeeding immediately after birth, preferably within one hour.
 Exclusive breastfeeding for the first six months i.e., the infants receives only
breast milk and nothing else, no other milk, food, drink or water.
 Mother should communicate, look into the eyes, touch and cares the baby
while feeding.
 Appropriate and adequate complementary feeding from six months of age
 Continued breastfeeding up to the age of two years or beyond.
 WHO growth charts recommended for monitoring growth.
1. The main goals of NHM are:
 To reduce MMR to 1/1000 live births
 To reduce IMR to 25/1000 live births
 To reduce TFR to 2.1
 Prevention and reduction of anaemia in women aged 15–49 years
 Prevent and reduce mortality & morbidity from communicable, non-
communicable; injuries and emerging diseases
 Reduce household out-of-pocket expenditure on total health care
expenditure
 Reduce annual incidence and mortality from Tuberculosis by half 8
 Reduce prevalence of Leprosy toreduce prevalence of Leprosy to
<1/10000 population and incidence to zero in all districts
 Annual Malaria Incidence to be <1/1000
 Less than 1 per cent microfilaria prevalence in all districts
 Kala-azar Elimination by <1 case per 10000 population in all blocks
2. Components of child health care under RMNCH+A include:
For Adolescents and women in reproductive age health care
 Adolescent nutrition, iron and folic acid supplementation
 Facility-based adolescent reproductive and sexual health services
(Adolescent health clinics)
 Information and counsellling on adolescent sexual reproductive health
and other health issues
243
Public Nutrition  Menstrual hygiene and preventive health checkups.
 Prevention and management of sexually transmitted and reproductive
infections (STI/RTI)
 Comprehensive abortion care (includes MTP Act)
 Community-based promotion and delivery of contraceptives
For maternal and child health care
 Immediate essential newborn care and resuscitation
 Delivery of antenatal care package and tracking of high-risk pregnancies
 Postpartum care for mother and newborn
 Home-based newborn care and prompt referral
 Facility-based care of the sick newborn
 Integrated management of common childhood illnesses (diarrhoea,
pneumonia and malaria)
 Child nutrition and essential micronutrients supplementation (IFA, Vitamin
A)
 Immunisations
 Early detection and management of defects at birth, deficiencies, diseases
and disability in children (0–18 years)
3. The goals of Janani Suraksha Yojna (JSY) are:
 To reduce maternal mortality ratio and infant mortality rate.
 To increase institutional deliveries among BPL families.
1. a. PDS/TPDS
b. Gram Panchayat, Nagar Palikas
c. Antyodaya Anna
d. National Food for Work
e. State Department
2. The Food Security programmes were initiated in order to give access to all
people enough food for an active and healthy life. It aimed at the concept
of food security, that is to remove the imbalance between demand and supply.
The various food security programmes are:
i) Antyodaya Anna Yojana (AAY)
ii) Annapurna Scheme
iii) National Food for Work Programme
3. The PDS is an essential part of the GOI to alleviate poverty in our country,
and in turn ensure food security. The backbone of the PDS is the extensive
network of 4.62 lakh Fair Price Shops (FPS) that distributes essential
commodities such as, whaet, rice, sugar, imported edible oil and kerosene
244 worth more than 30,000 crore annually to160 million families.
The main highlights of the TPDS are as follows: Nutrition Policy and
Programmes
a. The commitment of the GOI to meet the requirement of food grains at
the scale 10 kg per month at specially subsidized rates for BPL families.
b. The provision to states, a transitory allocation to Above Poverty Line
(APL) population.
c. The issuing of special cards to BPL families and selling essential articles
under TPDS at subsidized rates, thus streamlining the PDS.
4. The beneficiaries of Annapurna Scheme are the senior citizens who have
remained uncovered under the new Age Pension Scheme (NOAPS). The
eligibility criteria for this scheme is –
a. the age of beneficiary should be 65 years or above,
b. the beneficiaries must be a destitute.
c. The beneficiary should not be in receipient of pension under the NOAPS
or State Pension Scheme.
5. The salient features of National Food for Work programmes are:
— to provide additional resources apart from the resource available under
Sampoorna Grammen Rozgar Yojana (SGRY) to 150 most backward
districts.
— Distribution of food grains as part of wages under the WFFWP is also
one of the focus of this programe.
245
Public Nutrition
UNIT 11 REVIEW OF NATIONAL
NUTRITION PROGRAMMES
Structure
11.1 Introduction
11.2 Rationale for National Nutrition Programmes
11.3 Appraisal of National Nutrition Programmes
11.3.1 National Iodine Deficiency Disorders Control Programme (NIDDCP)
11.3.2 National Nutritional Anaemia Control Programme (NNACP).
11.3.3 National Programme for Prevention of Nutritional Blindness due to Vitamin A
Deficiency.
11.3.4 Integrated Child Development Services (ICDS) Scheme
11.3.5 Pradan Mantri Gramodaya Yojana: Setbacks and New Challenges
11.3.6 National Programme of Nutrition Support to Primary Education (Mid-Day Meal
Programme)
11.3.7 Public Distribution System (PDS) and Targeted Public Distribution Programme
(TPDS)
11.3.8 Employment Generation Schemes
11.4 Limited Impact of National Nutrition Programmes in India

11.5 Costs of Improving Nutrition Situation in India
11.6 Let Us Sum Up
11.7 Glossary
11.1 INTRODUCTION
In Unit 10 we studied about various national nutrition programmes launched by
Government of India to combat malnutrition and nutritional deficiency disorders. The
programmes - their objectives, components, beneficiaries etc. were discussed in
details. Having gone through the text, you may have wondered whether these
programmes have made any impact in controlling the deficiency diseases or improving
the nutritional status of the population or not? In this unit, we will critically analyze
some of these programmes and get to know their successes and failures. We will also
learn why all these programmes when taken together have made limited impact in
reducing malnutrition. We will conclude by studying the priory actions required to
improve nutrition situation in India.
Objectives
l highlight rationale behind the national nutrition programmes,
l explain major findings of the studies conducted to review nutrition intervention
programmes,
l describe the actions to be taken to improve these programmes,
l elaborate on reasons for limited impact of nutrition programmes, and
l conclude the priority actions required to meet the National Nutrition Goals
246 by 2022.
We will begin our study by reviewing the rationale behind the launch of national Review of National
nutrition programmes. Nutrition
Programmes
11.2 RATIONALE FOR NATIONAL NUTRITION

PROGRAMMES
You have read in Units 3 and 4 that nutrition deficiency disorders due to reduced intake
of iodine, iron, vitamin A and calories are significant public health problems in India,
particularly among the underprivileged communities. These disorders have been
described as a silent emergency. The adequacy of iron, iodine and vitamin A play an
important role in growth and development of young children. Thus, the prevalence of
nutritional deficiency disorders like Iodine Deficiency Disorders (IDD), Iron Deficiency
Anaemia (IDA), Vitamin A Deficiency (VAD) and Protein Energy Malnutrition (PEM)
remains high in all states and Union Territories of the country. We have also learnt that
the primary cause of nutritional deficiency disorders is inadequate intake of food both
in terms of quantity and quality. This is further aggravated by impaired absorption of
nutrients due to infections and infestations. Poverty is another contributing factor of the
nutritional deficiency disorders. Poverty is often linked to inadequate food and nutrition
security, poor sanitation, lack of safe water and inadequate knowledge about child
feeding and rearing practices, which play a role in causation of malnutrition. In view
of all these problems and issues, we learnt that the Government has initiated national
nutrition programmes to improve nutrition situation in India. Nutrient deficiency
programmes were initiated to reduce/eliminate deficiency disorders. Integrated Child
Development Services was launched to achieve holistic development of child and
reduce malnutrition. Programmes like Public Distribution Scheme and Targeted Public
Distribution Scheme were initiated to improve the food and nutrition security of
vulnerable population. The Mid Day meals programme was started to provide
supplementary food to school children, as well as, to increase the enrollment and
attendance in schools. The basic aim of all these national nutrition programmes such
as ICDS, National Mid Day Meals programme etc. was to bridge the gap between
daily routine intake of nutrients and their actual requirements amongst the beneficiaries.
Having launched these programmes with specific objectives and rationale, let us now
critically review these programmes and learn about their achievements and failures.
11.3 APPRAISAL OF NATIONAL NUTRITION

PROGRAMMES
You might be aware that the purpose of appraisal or evaluation is to assess the
achievements of the programmes with reference to its stated objectives, activities and
utilization of its services by the target population. Evaluation also measures the impact
of the programme. Evaluation studies on national programmes should ideally assess all
the components of a national programme and its impact. However, except for ICDS,
majority of research studies have evaluated one or two components of the nutrition
programmes. For ICDS, several evaluations have been conducted in the past, which
have looked at the entire programme in totality. Thus, in this unit, we will discuss the
key findings of the research studies conducted to assess either partly or in totality the
impact of these programmes. We will briefly recapitulate the objectives and various
components of these programmes, discuss findings of research studies and describe
various actions suggested to improve these programmes. As discussed earlier, we will
review the following programmes:
l National Iodine Deficiency Disorders Control Programme (NIDDCP)

l National Nutritional Anaemia Control Programme (NNACP).
l National Programme for Prevention of Nutritional Blindness due to Vitamin A
Deficiency
247
Public Nutrition l Integrated Child Development Services Scheme (ICDS)
l Mid Day Meals Programme (MDM)
l Public Distribution System (PDS)
l Targeted Public Distribution System (TPDS), and
l Employment Generation Schemes
You already know that these programmes aim to reach significant segments of India’s
undernourished population, For example, poor households through PDS and employment
generation schemes, vulnerable population like pregnant and lactating women and
children 0-6 years of age through ICDS, and school children through (Mid-Day Meal
Programme). It is also important for us to know that in addition to the government
programmes, there are few direct private sector efforts for nutritional improvement
among the poor. Some NGOs concerned with health have focused on the treatment
or prevention of malnutrition among women and young children. While some others,
involved in a broad-based development efforts, have focused on community nutrition
measures, such as grain banks or food distribution. In the aggregate, however, these
efforts reach a miniscule proportion of the country’s poor, and would need to be
multiplied several hundred-fold to have a significant impact on India’s malnutrition
problem. In the short term, efforts would be useful to increase the attention of private
medical practitioners to nutrition, of media to malnutrition and its effects, and to
disseminate information about successful NGO programmes.
We will now critically analyze the function of national nutrition programmes as
enumerated above and see what kind of impact they have made on the nutritional
situation of vulnerable population. We will start with the National Iodine Deficiency
Disorders Control Programme (NIDDCP).
11.3.1 National Iodine Deficiency Disorders Control Programme

We have studied about the National Iodine Deficiency Disorders Control Programme
(NIDDCP) in Unit 10.
We know that goitre is the most explicit clinical manifestation of endemic iodine
deficiency. The problem of goitre is as old as human civilization with several
descriptions found in ancient texts. The term “Iodine Deficiency Disorders (IDD)”was
coined in the eighties following the realization that iodine deficiency is associated with
several physical and neurological disorders which we have already studied earlier in
Unit 3.
In the year 1962, the Government of India, encouraged by the results of iodized salt
supplementation trial in Kangra Valley, Himachal Pradesh launched the National Goitre
Control Programme (NGCP). However, due to several logistic problems like inadequate
production, distribution, poor quality control, public apathy and lack of coordination, the
programme could not make an impact. This programme was strengthened in 1984 after
the Goverment of India adopted the policy of universal iodization of all edible salt. In
the year 1992, the programme was renamed as National IDD Control Programme
(NIDDCP).
Currently, the programme is successfully implemented in the country. According to
NFHS-4 (2015-16) survey 93% households are using iodized salts. Among the
states, use of iodized salt is lowest in Andhra Pradesh (82%), Tamil Nadu (82%) and
Dadra to Nagar Haveli (41%). The possible reason is that it is economical to
transport salt by road network. The quality of salt moved by road is not subjected
to monitoring by functionaries of salt department. However, salt transported by
railways is monitored by salt department for its iodine content. Hence, the states
receiving salt by railways receive salt with adequate quantity of iodine.
248
Significant achievements have been made under NIDDCP. These include:- Review of National
Nutrition
i. According to the National Family Health Survey 2015-16 (NFHS-4) conducted by Programmes
Ministry of Health and Family Welfare, 93 percentage of Households had Iodized
salt.
ii. Food Safety and Standards (Prohibition and Restriction on Sales), Regulation, 2011
restricted the sale of common salt for direct human consumption unless the same is
iodized.
iii. National Reference Laboratory for monitoring of IDD has been set up at National
Cooperative Development Corporation (NCDC), Delhi. Four Regional laboratories
one each at National Institute of Nutrition (NIN), Hyderabad, All India Institute of
Hygiene and Public Health, Kolkata, All India Institute for Medical Sciences
(AIIMS), Delhi have been set up to conduct training, monitoring, quality control of
salt and urine testing.
iv. For effective implementation of NIDDCP, 35 States/UTs have established IDD
Control Cells in their State Health Directorate. 35 States/UTs have set up State
IDD monitoring laboratories in their respective States/UTs.
v. Extensive Information Education Communication (IEC) activities have been carried
out to create awareness about the regular consumption of iodated salt in prevention
and control of IDD through Doordarshan, All India Radio, Directorate of Field
Publicity, Song and Drama, Directorate of Advertising and Visual Publicity.
Several studies have also been conducted in different parts of the country to look at
various components of the programme. These studies have made an attempt to assess
certain issues like 1) knowledge, attitude and practices (KAP) about NIDDCP
amongst the beneficiaries, 2) availability of iodized salt, 3) impact of iodine
supplementation on reduction of goitre prevalence and 4) adverse health consequences,
if any, of iodine supplementation under NIDDCP. Major findings of these studies show
that:
l Awareness levels about the causes of IDD and their prevention and control is
poor amongst the beneficiaries which has contributed to low demand and
utilization of iodized salt.
l Families are consuming salt with iodine content of less than recommended levels
of 15 ppm. Thus, although the salt is being iodized, either an inadequate quantity
of iodine is added at the production level or there are losses of iodine at the
different channels of distribution.
l There are beneficial effects of iodine supplementation through iodized salt in
prevention of goitre and improvement in urinary iodine excretion levels indicating
improved iodine nutriture.
l Prolonged consumption of iodized salt is not associated with ill effects due to
extra iodine intake.
Thus, having seen that awareness levels about the causes, prevention and control of
IDD, is low amongst households and families are consuming salt with less than
recommended levels of 15 ppm, certain priority actions have been suggested to bring
about improvement in aspects of programme implimentation. These are as follows:
Actions for improvement
l Regular monitoring of quality of salt at the manufacturer and consumption level
should be done to ensure that the beneficiaries consume adequate quantity of
iodine.
l There should be continued and sustained supply of iodized salt in iodine deficient
endemic areas.
249
Public Nutrition Thus, we can conclude that although the programme has made significant
achievements, we still have a long way to go for achieving complete coverage under
the programme.
Let us now move on to the National Nutritional Anaemia Control Programme
(NNACP).
11.3.2 National Nutritional Anaemia Control Programme (NNACP)

We have read in Unit 3 that Iron Deficiency Anaemia (IDA) is the most common and
the most neglected of nutritional deficiency disorders. In India, nearly 80 percent of
the pregnant women, 55 percent non-pregnant non-lactating women, 23 percent men
and more than 70 percent of adolescent and young children suffer from IDA. In under
privileged communities, iron deficiency is the most common cause of anaemia and
hence anaemia and IDA are used as synonyms in these communities.
The Government of India initiated National Nutritional Anaemia Prophylaxis Programme

(NNAPP) in 1970, which was subsequently renamed in 1992 as the National Nutritional
Anaemia Control Programme (NNACP). We have read studied about about NNACP
in Unit 10. Except for one ICMR national study which has evaluated NNACP in
totality, other evaluations pertain to specific components of NNACP like 1) awareness
amongst women and communities about the value of IFA tablets 2) awareness
amongst health workers about NNACP objectives 3) availability and distribution of
IFA tablets, 4) consumption of IFA tablets 5) monitoring of NNACP by health
workers 6) impact of IFA supplementation on birth weight and incidence of low birth
weight infants and 7) chemical composition of IFA tablets. Major findings of these
studies show that:
l There is lack of awareness amongst women and communities about the
consequences of anaemia and importance of taking IFA tablets. Many women
who receive the tablets do not consume these.
l There is lack of awareness amongst health workers about NNACP objectives
and health consequences of iron deficiency anaemia. They lack awareness about
IFA distribution. i.e. age group of beneficiaries, especially for small tablets,
dosage, side effects and management of side effects.
l There are major shortages of IFA tablets across the country.
l There is inadequate consumption of IFA tablets by women and children due to
a) poor supplies b) lack of compliance c)lack of worker motivation d) lack of
nutrition and health education by health workers and e) lack of follow up by
health workers.
l There is lack of monitoring by the medical officers in charge of primary health
centers for implementation of the NNACP.
l Iron supplementation as per programme guidelines shows beneficial effects in
improving the birth weight and lowering the incidence of low birth weight infants.
l Chemical analysis of the IFA tablet shows less than recommended levels of iron
and folic acid content of the tablet.
Based on these findings, it emerges that even today, there is poor coverage and high
levels of anaemia persist in pregnant women and preschool children. The priority
actions needed for improving the programme are stated as follows:
l to improve the nutritional and health status of children in the age-group 0-6 years;
l to lay the foundation for proper psychological, physical and social development of
250 the child;
l to reduce the incidence of mortality, morbidity, malnutrition and school dropout; Review of National
Nutrition
l to achieve effective co-ordination of policy and implementation amongst the Programmes
various departments to promote child development; and
l to enhance the capability of the mother to look after the normal health and
nutritional needs of the child through proper nutrition and health education.
We will now move on to the National Programme for Prevention of Nutritional
Blindness due to Vitamin A deficiency (VAD).
11.3.3 National Programme for Prevention of Nutritional

Blindness due to Vitamin A Deficiency (VAD)
We have studied about the National Programme for Prevention of Nutritional Blindness
in Unit 10. In 1992-93, the programme was brought under the Child Survival and Safe
Motherhood (CSSM) programme in which, universal coverage of children with vitamin
A doses was targeted to 1-3 yrs of age. Also, an additional component of therapeutic
administration of vitamin A was included in the programme. Accordingly, the therapeutic
doses of vitamin A were to be given to children: suffering with eye signs of VAD,
diarrhoea, measles and severe PEM with eye signs of VAD. The current beneficiaries
include all children from 9 months to less than 5 years of age.
Currently, the main focus of the programme is on synthetic vitamin A supplementation
without consideration of prevalence of under five mortality and infant mortality rates,
dietary intake of vitamin A and prevalence of ocular signs of VAD. For example, the
state of Kerala has the same policy of vitamin A supplementation as in Uttar Pradesh.
Sustainable strategies like promoting intake of vitamin A rich foods are given low
priority.
There are no studies which have evaluated all the components of Nutritional
Programme for Prevention of Prevention of Nutritional Blindness due to VAD hence,
we would discuss major findings of studies conducted to assess the various components
of the National Programme of Prevention and Control of nutritional blindness due to
vitamin A.
These studies have focused on 1) prevalence of VAD in the country 2) coverage of

vitamin A supplementation in the country and 3) impact of vitamin A supplementation
on mortality and morbidity amongst children.
Major findings of the studies show that:
l VAD is a public health problem in certain geographical pockets/districts of the

country. Some of these districts are Gaya, Patna and Bikaner, located in socio-
economically poor regions of the country.
l According to NFHS by Survey, 60% of children aged 6-59 months were given
vitamin A supplements in past 6 months proceeding the survey and 44% of
children aged 6-23 months consumed vitamin A rich food in the day or night
before the interview.
l Coverage levels of VA supplementation to the children are low due to various

reasons like inadequate outreach, inadequate and irregular supplies, lack of
orientation of functionaries, lack of monitoring and supervision, vertical approach
of the programme with total lack of community involvement and participation and
complete absence of education and communication.
l Evaluation of the impact of vitamin A supplementation on mortality and morbidity

shows no significant impact of vitamin A on mortality and respiratory tract
infections among children.
251
Public Nutrition Thus looking at the findings that VAD remains a public health problem in certain
geographical pockets and coverage of vitamin A supplementation is low, certain
priority actions for improving the vitamin A prophylaxis programme are suggested as
follows:
l Consumption of vitamin A rich foods should be especially promoted in areas found
to be deficient in vitamin A.
l The programme should be strengthened through various measures like improvement
of community outreach, adequate training of functionaries, provision of regular
and adequate supplies of vitamin A supplements, community participation and
nutrition education and communication.

1. Write some of the achievements made under NIDDCP.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
2. Mention the priority actions required to improve the NIDDCP.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
a. One major findings of studies conducted to evaluate NNACP.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
b. Priority actions required to improve the NNACP.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
a. Major findings of the studies conducted to evaluate Vitamin A prophylaxis
programme.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
252
Review of National
b. Priority actions needed to improve the Vitamin A prophylaxis programme. Nutrition
Programmes
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
Let us now move on to Integrated Child Development Services Scheme.
11.3.4 Integrated Child Development Services (ICDS) Scheme

Integrated Child Development Services (ICDS) Scheme was launched on Oct.2, 1975
in pursuance of National Policy for children. We know that currently the scheme is the
largest nutrition programme launched by Government of India for the holistic development
of the child through interventions in nutrition, health and education.
As per the date of 2014-15, 102.23 million children and pregnant and lactating mothers
are actually covered by supplementary feeding and only 36.54 million 3-6 year-olds by
preschool education. Coverage figures are not available for the other services. ICDS
also includes, in fewer than 10 percent of the 4200 programme blocks, schemes for
adolescent girls’ nutrition, health, awareness and skill development, and in some areas
it has been linked with women’s income-generating programmes. The impact of the
programme is evident from the remarkable improvement made in chief survival and
development indicators as enumerated below:
l decrease in prevalence of malnutrition among preschool children
l improved immunization coverage in ICDS areas
l improvement in school enrolment and reduction in school dropout rate in ICDS
areas.
The most important impact of the scheme is clearly reflected in significant decline in
the levels of severely malnourished and moderately malnourished childrn and Infant.
Mortality Rate in the country. According to NFHS-4 Survey, the percentage of childern
suffering form malnutrition have significantly declined. Since 2005-06, stunting declined
from 48% in 2005-06 to 38% in 2015-16. Over this period prevalances for wasting
has remained about the same. The infant Mortality Rates have also declined from 53
per 1000 live birhts in 2008 to 34 during 2016 (Sample Registration System, 2016).
The programme is targeted at poor areas, and increasingly at poor households.

Programme guidelines call for the food supplements (which are limited to 40 percent
of the expected beneficiary population of an anganwadi) to be given preferentially to
children and pregnant women from households at high risk of malnutrition - those of
landless labourers, marginal farmers, scheduled castes or tribes. The adolescent girls’
and women’s programmes are intended to improve health and nutrition over the longer
term through improvements in women’s skills and access to resources. However,
evaluations of ICDS have found its impact on nutritional status to be limited. The
reasons for this are:
 inadequate coverage of children below 3 years of age, of those at greatest risk
of malnutrition, and of women and children living in hamlets,
 irregular food supply, irregular feeding and inadequate rations,
 poor nutrition and health education of mothers (and none of families) to encourage
improved feeding practices in the home and other relevant behavioural changes,
253
Public Nutrition  inadequate training of workers, particularly in nutrition, growth monitoring, and
communication,
 anganwadi worker’s (AWW) overload, weak and unsupportive supervision of

AWWs resulting in the neglect of crucial nutrition-related tasks, and
 poor linkages between ICDS and the health system.
In general, the quality of ICDS services needs great improvement. The programme’s
services are much in demand, but they are inadequately delivered and often
uncoordinated. Worker training, in-service supervision and community involvement
remain major gaps. Although, there are exceptions, anganwadi facilities and environments
need to be enhanced and the programme needs to inspire good health, hygiene and
nutrition related behaviours that are essential to improving the nutrition and health
status of children and women in poor households. To make a significant impact on
nutrition and health, a great number of improvements are needed in ICDS. Thus,
priority actions needed to improve the programme are:
Actions for improvement:
l Improve the nutritional and health status of children in the age-group 0-6 years;
l Lay the foundation for proper psychological, physical and social development of
the child;
l Reduce the incidence of mortality, morbidity, malnutrition and school dropout;
l Achieve effective co-ordination of policy and implementation amongst the
various departments to promote child development; and
l Enhance the capability of the mother to look after the normal health and
nutritional needs of the child through proper nutrition and health education.
ICDS during the 12th Plan:
Since its genesis, the ICDS has constantly gone through several stages of improvement
in terms of enforced implementation and sustainability of its objectives. Thus, in the
12th year plan of the planning commission has focused on the following.
 Repositioning theAWC as a “vibrant Early Childhood Development (ECD) centre”

to become the first village outpost for health, nutrition and early learning – minimum
of six hours of working, etc.
 Strengthening early childhood care and education, Care and Nutrition Counselling
service for mothers of under-3s and Management of severe and moderate
underweight.
 Improving Supplementary Nutrition Programme with revision of cost norms.
 Nutrition Counsellor cum Additional Worker in 200 high burden districts and link
workers in others district.
 Creation of a separate ICDS Mission Budget head to allow flexibility and integration
within the child development and nutrition sectors and for convergent action with
wider determinants of maternal and child under-nutrition.
 The ICDS Mission targets would be to attain three main outcomes namely; i)
Prevent and reduce young child under-nutrition (% underweight children 0-3 years)
by 10 percentage point; (ii) Enhance early development and learning outcomes in
all children 0-6 years of age; and (iii) Improve care and nutrition of girls and women
and reduce anaemia prevalence in young children, girls and women by one fifth.
Annual Health Survey (AHS) and District Level Household Survey (DLHS) to be
used as baseline for measuring the outcomes of ICDS mission.
254
Thus, we see that ICDS must greatly improve the quality of its services and their impact Review of National
on the vulnerable groups. Both the quality of their services and impact must be regularly Nutrition
Programmes
monitored and evaluated and improvements made continuously.
11.3.5 Pradhan Mantri Gramodaya Yojana: Setbacks and New
Challenges
You may recall reading about the Pradhan Mantri Gramodaya Yojana (PMGY) earlier
in Unit 1 and 10 which focuses on the creation of social and economic infrastructure
in the area of health, nutrition, education, drinking water, housing and rural roads. Now
we shall look at the new changes bought about in PMGY. This includes an allocation
of 15% funds for nutrition component as you may recall studying in Unit 10. This was
done as poor and populous states with high under nutrition rates did not get sufficient
funds.
Some of the available data today indicates that the major setbacks of this yojana are:
l Difficulty in procuring locally available take-home food supplements
l Provision of relatively expensive ready to eat food was made, rather than the
cereal-pulse-oilseed mixture.
l The funds provided under the nutrition component of PMGY were not treated as
an additionality but were substituted for states own plan funds for nutrition.
l There has not been any substantial improvement in the enrolment of children.
The guidelines laid down for the nutrition component of PMGY emphasize that all
infants and children should be weighed at least once in three months to detect those
who are undernourished so that health and nutrition interventions could be
undertaken. Under the Twelth Five Year Plan, the physical and financial evaluation
and the impact of the programme on infant feeding practices or infant nutritional status
are taken up.
We will now move on to National Mid Day Meals Programme also known as National
Programme of Nutritional Support to Primary Education.
11.3.6 National Programme of Nutrition Support to Primary

Education (Mid-Day Meal Programme)
Mid Day Meals scheme is the common name used for National Programme for
Nutritional Support to Primary Education (NSPE). We studied about the coverage,
salient features and implementation of the programme in Unit 10. We suggest you look
up the sub-section 10.6.1 in Unit 10. Here, our focus would be to critically review the
programme.
NSPE is being implemented in all States/UTs except Jammu and Kashmir and
Lakshadweep (the latter runs its own programme). It covered 9.46 crore children
benefited by hot cooked food in 11.34 lakh school during 2017-18. In 2007 when the
scheme was extended to cover upper primary children from backwards block, the
scheme name changed from NSPE to MDMS.
All States and 7 UTs provide cooked meals to all primary school children, while 9
states provide cooked meals in some areas only. All states are distributing food grains
under the programme. However, in the interim, until the institutional arrangements are
made, states continue to provide food grains. Let us review the evaluation of MDM.
Evaluation of MDM
To ensure effective implementation of the Mid-Day-Meal scheme, there is a detailed
monitoring mechanism at the school, block, district, State and the National level. According 255
Public Nutrition to the reports of the State Governments, till 30th September 2018, more than 5 Lakh
inspections have been carried out. In addition 36 independent Monitoring Institutes have
been engaged with defined terms of reference to monitor and supervise the Scheme on
a biannual basis. The Supreme Court Commissioners have also evaluated the scheme in
six States of the country.
Findings of the evaluation studies by independent organizations in various states
indicate the following impacts.
l The Cooked Day Meal Program has been successful in addressing “classroom
hunger” in the beneficiary schools, as many children come to school empty stomach
or, those coming from distant places, again feel hungry on reaching school, and thus
cannot concentrate on studies.
l The contribution of mid-day meals to food security and child nutrition seems to be
particularly crucial in tribal areas where hunger is endemic.
l Mid Day meals have big effects on school participation, not just in terms of getting
more children enrolled in the registers but also in terms of regular pupil attendance
on a daily basis across all the states and more importantly narrowing the gender
gaps in school attendance rates.
l Cooked Mid Day Meal is reported to have created a platform for children of all
social and economic backgrounds to take meals together, thereby facilitating achieving
the objective of social equity.
l Mid day meal has also helped the poor families that, engulfed in poverty, hunger and
starvation striving hard to have one square meal a day, can not even think of sending
their children to schools. The poor households such as those headed by widows or
landless labourers value that assurance of a free lunch every day for their children.
l This programme has created a very congenial atmosphere for education, health
growth and overall well-being of the poor and needy children.
l National Council of Educational Research & Training’s latest report states that
Learning Achievement of Students at the End of Class-V has inferred that children
covered under mid day meal have higher achievement level than those who were
not covered under it.
l The Scheme has created various good habits in children, such as washing one’s
hands before and after eating, use of clean water , good hygiene etc.
l Since key objective of NSPE is to provide a boost to primary education, it is
critical not only to strengthen the various programme components but also to
design strategies to reach out of school population. This and other issues could
be addressed by greater involvement of the community and Panchayati raj
institutions.
l There is a need to set up a separate cell for implementation of NSPE with full
time staff. Presently, the Ministry of Human Resource Development is the
national agency for the programme implementation, while at the state level, in all
states except Rajasthan, Madhya Pradesh and Orissa, the implementing body is
the Department of Education. There is little interaction between state agencies
and the Food Corporation of India (FCI). Inter-linkages between the FCI and the
implementing agency need to be improved for timely delivery of food grains.
l School records should be maintained on key indicators of the programme and
data can be aggregated at various levels.
l There is need to improve the monitoring and supervision across states on various
256 aspects of the programme such as: quantity and quality of food grains and
cooked meals, timely delivery and frequency of distribution to eligible students. Review of National
Nutrition
As you may note that this review was conducted for ten states only. Therefore, it is Programmes
widely suggested that a process and impact evaluation of NSPE be conducted on an
all India basis. This process and impact evaluation should include the following:
l The reactions of the key participants at the grass root level, namely the schooler,
the teacher and the local Ration Shop keeper about the programme.
l Linkages formed by the programme, if any, with the Primary Health Centre, the
Village Panchayats, and the ICDS.
l The positive and negative aspects of the NSPE versus Hot Meal Variant.
l Impact on nutritional status and cognitive development among the children.
In other countries, school feeding has been found to increase learning achievement
more when provided as a “breakfast” to hungry children than as a noon meal. The
NSPE will have no impact whatsoever on the nutritional status of that child unless she/
he consumes adequate food. To enhance nutrition and health status, food intake would
need to be assured and accompanied by deworming, vitamin A and iron, supplementation
and control of infections. These improvements in the NSPE would require state
commitment to providing cooked meals at school, substantially increased management
capacity, improvements in the school health programme, and a larger quantum of
resources than is currently available from either GOI or the state governments. Thus,
following strategies have been suggested to achieve the nutrition and health objective
of the programme.
Suggestions
l Government needs to establish a system to ascertain improvement in nutritional
levels of children. It should coordinate with the concerned department and ensure
maintenance of health cards in all the schools to monitor the health status of the
children.
l There is a need to narrow the gap between enrolment vs. actual number of children
availing MDM.
l Monitoring and Supervision mechanisms should be implemented effectively. The
State government needs to strengthen the internal controls as well as the inspection
and monitoring mechanism at all levels.
l The quality of cooked food served needs to be enhanced.
l Nutritious items such as eggs and green vegetables should be provided regularly.
l Mid day meal should be integrated with school health services, including immunization,
deworming, growth monitoring, health checkups and micronutrient supplementation.
l It is essential that the children and the parents are given nutrition education, so that
MDM is not taken as a substitute for home food but as an addition to the food
provided by the family.
It is also important to understand that policy makers and the implementers of the NSPE
must fully realize that if hard choices are to be made, it would benefit the schooler
more to give him/her a health package of deworming, iron, vitamin-A, and iodine,
rather than just food grains. The cost of health package is estimated at Rs.10/- child
per year. Thus, for about 200 million primary school children in India, the total cost
of the Health Package in the Classroom, would come to: Rs. 2000 million. (200 million
primary school age children × Rs.10 per child = Rs.2000 million). Wheras, the yearly
expenditure of food grains for this group comes to about Rs.10,000 million. The best
proposition would, of course, be to give the schooler both the Hot Meal plus the
Health Package in the classroom.
Next, let us review the Public Distribution System.

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Public Nutrition
11.3.7 Public Distribution System (PDS) and Targeted Public
We studied about Public distribution system in and Unit 10. PDS is a food subsidy
programme implemented by Government of India to provide food security to the poor
people in India. PDS provides cereals and other essential items to cardholders at
subsidized rates.
Various studies have been conducted to review PDS. While PDS has been an
important buffer against local food shortages, it has fallen short in many respects as
a measure to provide food security to the poor. Major findings of these research
studies show that:
l PDS has been inadequately targeted, with a large number of beneficiaries

actually coming from non-poor households.
l Many of the poorer states do not obtain the requisite quantities to cover their
needy populations - they take less than their share of supplies from the PDS
mainly because of weak administrative capacity and inability to move the food
stocks.
l There are serious leakages in the programme, with supplies often finding their
way to the open market.
l The PDS is a high-cost operation relative to the caloric support it provides: it

costs about three times as much for the PDS to provide a given number of
calories to a household, compared with ICDS.
l As late as 1997, access of the poor to the PDS was very limited, and particularly
weak in the states with the highest incidence of poverty.
Thus, taking into consideration the various research findings about PDS, government
introduced the Targeted Public Distribution System (TPDS) in early 1997. Let us now
review the TDPS.
Targeted Public Distribution System (TPDS)
We know that the Central Government introduced the Targeted PDS (TPDS) aimed
at better coverage of households below the poverty line. Under the TPDS, BPL
households are given a special identity card to obtain up to 20 Kg (with respect to
April, 2000) of rice or wheat per month at specially subsidized rates.
No review has been conducted of TPDS so far. However, while the TPDS is designed
to improve food supplies in the poorest households, it has not gone far enough in a
number of ways. Some of the criticism which TPDS faces are:
l Despite a very heavy subsidy burden, the TPDS has come in for severe criticism
from various quarters including many State Governments. It has been argued that
a scale of ration of 20 kilograms per month per BPL family is grossly inadequate
since the average requirement of a family is about 30 kilograms per month. The
quantity of subsidized grain provided amounts to a marginal supplement of 100
calories per person per day, far less than the estimated gap of poor people in rural
areas.
l Secondly, the PDS in most states still provides large quantities of subsidized food
to non-poor households, although this food could be targeted at needy children and
mothers, for example, through ICDS.
258
l It is unclear how the TPDS will plug leakages, particularly in the absence of a Review of National
Nutrition
rigorous monitoring system.
Programmes
We would like to bring this to your attention that people need not just food grains but
also other food items such as pulses, milk, fruits and vegetables for improving their
nutritional status. We know that India’s food grain production has continued to
increase fairly steadily, though population growth has eroded these gains somewhat.
The per capita availability of food-grains was 384 kilograms in 1960 and 464 kilograms
in 1996. Unfortunately, however, the production of pulses, an important constituent of
the vegetarian Indian diet, has fallen from 65.5 kilograms per capita to 34 kilograms
in the same period, although availability has been boosted somewhat by imports. To
ensure proper nutrition, adequate quantities of pulses or other protein-rich foods such
as milk, eggs, or meat (which are also in short supply) must become more widely
accessible, requiring increased production, improved distribution and consumption.
Unless the prices of these commodities are reduced substantially -- through vastly
increased availability - they will remain out of reach of the poor.
Let us next review the Employment Generation Schemes.
11.3.8 Employment Generation Schemes

We studied about some of the employment generation schemes like Food For Work
Programme, Sampoorna Gramin Yojana etc. earlier in Unit 10. However, there is little
independent corroboration of the extent to which the employment programmes have
supplemented the incomes and food available to the poor, though they are intended for
this purpose. The programmes unfortunately suffer from managerial problems so that
it cannot be assumed that the number of person-days of work they provide accrue fully
to the poor. The efforts of the employment programmes to provide household food
support by part payment in grain need to be strengthened, and the programmes have
also to meet other nutritionally-relevant objectives, such as ensuring that 30 percent of
beneficiaries are women, and raising participant families above the poverty line.
In this unit, so far, we have reviewed several nutrition programmes and pointed out the
main deficiencies in each of the nutrition-related programmes. So now the question
arises why all these programmes taken together have had a limited impact to combat
malnutrition successfully. Let us now look at some of the reasons for this and what
we can do to improve the situation. But first let us recapitulate what we have learnt
so far.
1. List the reasons for limited impact of ICDS on nutritional status of vulnerable
groups.
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2. List the priority actions suggested to improve the ICDS scheme.
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Public Nutrition
3. If an all India Process and Impact evaluation is planned for Nutritional Support
to Primary Education Programme, what are the key components you would
include in the evaluation?
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4. What criticism does TPDS faces from different states?
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Next let us find out why the programmes discussed above have had a limited impact
to combat malnutrition.
11.4 LIMITED IMPACT OF NATIONAL

NUTRITION PROGRAMMES IN INDIA
Having reviewed all these programmes, it becomes necessary to ask this question as
to why all these nutrition programmes taken together have not been very effective
to combat malnutrition successfully in India. You would have noted by now that each
programme appears well-conceived, but in most cases implementation has been weak
- particularly with regard to ensuring the access of the poor. There are also virtually
no synergies between the programmes. There is also a shortage of funds for
expanding coverage and improving the quality of the programmes.
Thus, some of the reasons why nutrition programmes taken together have not been
very effective to combat malnutrition successfully in India are poor implementation,
inadequate coverage of BPL families and poor synergies between programmes. We
will explain these in detail now. Let us start with poor implementation.
l Poor implementation: There are many issues, which need to be addressed for
successful implementation of these programmes. These issues relate to coverage,
targeting, awareness building, training, supervision, monitoring, community
participation and logistics including supply and distribution. Overall, the direct
nutrition programmes are insufficient to the task, uncoordinated, lack regular
monitoring and evaluation, and have limited impact. If the current programmes
were properly targeted, rationalized and improved in quality, they could succeed
in substantially reducing malnutrition within the next two decades, particularly in
the context of India’s projected economic growth over this period. Recent
developments in India, such as economic reforms, globalization processes, and the
high skill-intensity of demand for labor, may increase the poor’s vulnerability to
shocks, and emphasize the need to strengthen programmes such as ICDS and
TPDS.
l Poor synergies between all the programmes: Although the nutrition-specific

actions are embedded in a broader policy framework that emphasizes employment-
intensive economic growth, greater access to social services, and specific poverty
alleviation measures, the potential synergies among these wider efforts and the
direct nutrition programmes remain largely undeveloped. There is a great need
to bring about coordination among the many institutions involved in the nutrition-
related sectors. Key institutions such as the National Nutrition Council and the
Department of Women and Child Development have important roles to play in
advocating and implementing enhanced efforts for nutrition.
l Inadequate coverage of BPL families by all the programmes: The grinding
260 poverty of rural and urban slum dwellers in India suggests that BPL households
need to be reached by all the programmes mentioned above, that is, the Review of National
employment schemes and TPDS to ensure adequate income and food availability Nutrition
Programmes
to poor households; ICDS to care for the nutrition and health care needs of
vulnerable women and children; and the mild day meal programme to provide
school children with both the incentive and nutritional support to learn. However,
the affordability of all these programmes is questionable and, therefore, in the
context of inadequate resources, it is necessary to examine and weigh their
relative costs and contribution to achieving nutritional objectives.
This brings us to the next issue, a most important issue, indeed, about having funds and
resources for expanding coverage of the programmes. One would believe that we do
need additional funds to expand coverage and improve the quality of the programmes.
But we can also argue that some of the improvements in the programme could be done
without increasing the cost of the programmes. Let us critically look at this aspect. The
next section reviews the costs of improving nutrition in India.
11.5 COSTS OF IMPROVING NUTRITION

SITUATION IN INDIA
You would note that many of the actions needed to improve the nutrition programmes
involve relatively little additional cost. Assigning higher priority to nutrition training,
devolving responsibility to the state, district and village level, and fostering greater
health-nutrition collaboration do not increase the cost of the programmes. Having a
second village-level worker for health or preschool education will involve additional
cost, but not a very large one, especially in the context of overall spending on food and
nutrition. On the other hand, expanding ICDS or National Mid-Day Meal Programme
to fully cover their target groups would require a large increase in funding. What we
need most in improving the nutrition programmes are political will, community
ownership, strengthening the work ethic, and supporting workers with the tools they
need to do their jobs. The most important of all these is the adequate and sustained
commitment at all levels, especially political levels.
Let us discuss in detail about political commitment.
Political commitment: Malnutrition fails to receive the priority it deserves in India, as

in many other countries, because it is largely invisible, and also because programme
efforts must extend across many sectors and levels. The most important factor is that
sustained political commitment is required for the long and difficult task of prevention
of malnutrition. Due to inadequate political commitment, the programmes are therefore,
not able to reach the poor, who are malnourished and therefore most in need of
assistance. Sustained allocations and proper direction of the necessary financial and
human resources would demonstrate political commitment in favour of improved
nutrition.
Under the National Nutrition Policy, we had set certain National Nutrition Goals to be
accomplished by year 2000, which were not achieved. Recently, another
flagship programme named 'POSHAN ABHIYAAN' is launched in 2018, that target
to reduce stunting, undernutrition, anaemia and low birth weight by 2%, 2%, 3% and
2% per annum respectively. You may recall reading about this in Unit 10, under
section 10.4. To achieve the target set under NNP it demands certain actions and
demonstrated success in four areas.
First, the country must put into place the leadership structure and administrative
capacity to ensure commitment to, and management of, the programmes required to
deal with the massive challenge. This encompasses the policy, planning and
implementation structure, and the institutional and individual capacities necessary to
make it work effectively.
261
Public Nutrition Second, the ICDS programme must greatly improve the quality of its services, and
their impact on vulnerable groups. Both the quality of services and their impact must
be regularly monitored and evaluated - and improvements made continuously.
Third, the health sector must give higher priority to malnutrition and ensure that its
actions have far greater impact on the problem than they do now.
And fourth, India must do better at providing food security to the poor at the
community and household level. Sustained success in these four areas is essential if
India is to deal effectively with the crisis of malnutrition.
Let us study each of these in detail now:
1. Rebuilding Institutional Capacity
India must put into place the leadership structure and administrative capacity to
ensure commitment to, and management of, the programmes required to deal
with nutrtional problems. Thus rebuilding India’s capacity for nutrition action,
training, research and advocacy will require:
l high level policy, planning and implementation structure,
l involving panchayati raj institutions in a major way
l setting clear quantitative goals and auditing them at least annually in a high
profile national conference, and
l making key institutions such as National Institute of Nutrition (NIN) and

National Institute of Public Cooperation and Child Development (NIPPCD)
autonomous.
Additional funds will be needed for 10-15 years, on a sustained basis, in order to
assure a steady build up of capacity to undertake the tasks outlined above, and to
provide the environment necessary to attract scientists and other professionals to
careers in nutrition. Since the achievement of nutritional goals is a responsibility
shared amongst several departments, reallocation of resources across departments
must be guided by their relative effectiveness in combating malnutrition. Approximately
Rs. 25 crores per year will be needed for NIN and NIPCCD, plus about Rs. 100
crores per year for 20-25 colleges of home science, medicine or other nutrition-related
institutions.
2. Enhancing the Quality and Impact of ICDS
We have discussed earlier that ICDS programme must greatly improve the quality of
its services. The priority actions needed in ICDS are:
l improvement of nutritional and health status of children belonging to age group

0-6 years;
l enhancing quality and impact through better training, supervision, and community
ownership;
l establishing a reliable monitoring and evaluation system as soon as possible; and
l effective cordination of policy and implementation amongst the various departments

to promote child development.
Measures to decentralize ICDS and place its management increasingly in the hands
of panchayati raj institutions are likely to be budget neutral in the medium term, but
262
extensive training will cost additional resources. Additional resources of about 150 Review of National
crores would also be required for the second worker and the quality improvements Nutrition
Programmes
that are necessary. Thus, if sincere efforts are made, then improving the quality and
impact of the programme should be achievable within 3-5 years. Following this,
reaching all those in need nationally, i.e., the one-third of families living in poverty,
would cost on the order of an additional Rs. 1250 crores a year. In all ICDS will need
an additional Rs. 1500 crores/year to have a substantial impact on malnutrition.
3. Strengthening the Contribution of Health Sector
The health sector must give high priority to malnutrition and ensure that its action have
far greater impact on the problem than they do now. The priority actions needed to
strengthen the contributions of the health sector are:
l training programmes to assure a quantum leap in the nutrition knowledge and

capacity of all levels of health workers
l much greater synergy with nutrition programmes, especially ICDS, and especially
by focusing ANM-AWW collaboration on 6-24 month olds and pregnant women.
The cost for this would not exceed Rs. 25 crores annually.
4. Improving household Food security through TPDS and Mid Day Meals
Programme
India must do better at providing food security to the poor at the community and
household levels. You read about Targeted Public Distribution programme (TPDS) and
National Mid Day Meals Programme in Unit 2 and Unit 10. These programme provide
food security to vulnerable population including school children. Certain actions could
be taken for improving these programmes which could improve the food security of
the vulnerable population.
Let us first consider TDPS. The urgent priorities for TDPS are:
l effective coverage of the poor, and shifting the food subsidy entirely to the
population below the poverty line
l careful monitoring to ensure benefits reach the poor
l ensuring that the vulnerable are reached quickly with needed supplies during
droughts and other disasters.
Next, let us consider NMMP.
Increasing the impact of NNMP: Increasing the impact of NNMP could be achieved
by these actions:
l targeting NMMP by area, using low educational attainment and poverty criteria,
and
l targeting food on preschool, as well as, primary school children, in areas not
covered by ICDS
These goals could be achieved without additional resources and would increase
substantially the overall education and nutritional impact, and the cost-effectiveness of
the programme.
Total Cost: If we calculate the total cost of improving nutrition programmes, then by
one estimate, it would be Rs. 400 crores/year. While for a period of ten years, it would
263
Public Nutrition be a total investment of around Rs. 4000 crores, excluding the cost of expanding
ICDS. Since the achievement of nutrition goals is a responsibility shared amongst
several departments, reallocation of resources across departments must be guided by
their relative effectiveness in combating malnutrition. When one considers that the
cost of malnutrition in lost productivity, illness and death is at least Rs. 50,000 crores
annually, the cost-benefit ratio of these investments is readily apparent.
1. List the three reasons why nutrition programmes when taken together are not
able to reduce malnutrition in India?
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2. What key actions are required if we want to achieve the National Nutrition
Goals by 2022.
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11.6 LET US SUM UP

The Government of India has launched many programmes to improve nutrition situation
of India. Some of these programmes include nutrient deficiency programmes to combat
micronutrient malnutrition; ICDS for holistic development of children through
interventions in health, nutrition and education and for reduction of malnutrition; and
PDS and TDPS for improving food and nutrition security. However, when taken
together, these programmes have not been very effective in reducing malnutrition. The
main reasons identified relate to lack of political commitment, poor implementation,
inadequate coverage of BPL families, poor synergies between programmes and lack
of funds. Key actions are required in four different areas if we want to achieve the
National nutrition Goals by 2022, First, the country must put into place the leadership
structure and administrative capacity to ensure commitment to, and management of,
the programmes required to deal with the massive challenge. Second, the ICDS
programme must greatly improve the quality of its services, and their impact on
vulnerable groups. Both the quality of services and their impact must be regularly
monitored and evaluated – and improvements made continuously. Third, the health
sector must give higher priority to malnutrition and ensure that its actions have far
greater impact on the problem than they do now. Lastly, India must do better at
providing food security to the poor at the community and household level. All this
would require a total investment of around Rs. 4000 crores over a period of ten years,
excluding the cost of expanding ICDS. When one considers that the cost of
malnutrition in lost productivity, illness and death at the rate of least Rs. 50,000 crores
annually, the cost-benefit ratio of these investments is readily apparent.
11.7 GLOSSARY
Beneficiaries : persons who benefit
Cluster : group sharing a similar characteristic
264 Corroboration : confirmation, Documentation
Diversification : expanded range Review of National
Nutrition
Fortification : strengthen Programmes
Genesis : origin, or mode of formation

Intersectoral : between more than one sector/department
Micronutrient : nutrient required by body in small quantities
Strategy : the art of planning for effective results

EXERCISES
1. Significant achievements have been made under NIDDCP. These include:-
i. According to the National Family Health Survey 2015-16 (NFHS-4) conducted
by Ministry of Health and Family Welfare, 93 percentage of Households had
Iodized salt.
ii. Food Safety and Standards (Prohibition and Restriction on Sales), Regulation,
2011 restricted the sale of common salt for direct human consumption unless
the same is iodized.
iii. National Reference Laboratory for monitoring of IDD has been set up at
National Cooperative Development Corporation (NCDC), Delhi. Four Regional
laboratories one each at National Institute of Nutrition (NIN), Hyderabad, All
India Institute of Hygiene and Public Health, Kolkata, All India Institute for
Medical Sciences (AIIMS), Delhi have been set up to conduct training,
monitoring, quality control of salt and urine testing.
iv. For effective implementation of NIDDCP, 35 States/UTs have established
IDD Control Cells in their State Health Directorate. 35 States/UTs have set
up State IDD monitoring laboratories in their respective States/UTs.
v. Extensive Information Education Communication (IEC) activities have been
carried out to create awareness about the regular consumption of iodated salt
in prevention and control of IDD through Doordarshan, All India Radio,
Directorate of Field Publicity, Song and Drama, Directorate of Advertising
and Visual Publicity.
2. Priority actions needed for improvement of NIDDCP are:
 Information Education Communication (IEC) activities should be undertaken
amongst the population regarding NIDDCP.
 Regular monitoring of quality of salt at the manufacturer and consumption
level should be done to ensure that the beneficiaries consume adequate
quantity of iodine.
 There should be continued and sustained supply of iodized salt in iodine
deficient endemic areas.
3. a. Major findings of the studies to evaluate NNACP show that :
 There is lack of awareness amongst women and communities about the
consequences of anaemia and importance of taking IFA tablets. Many
women who receive the tablets do not consume these.
b. The priority actions needed for improving the NNACP are :
 Information Education Communication (IEC) activities should be
undertaken amongst the women and communities about causes,
consequences of anaemia and importance of IFA and adequate diet in
prevention and control of anaemia.
265
Public Nutrition  Health functionaries should be adequately trained about the objectives and
implementation of the NNACP.
 Monitoring by health workers and the medical officers should be strengthened
about the implementation of the NNACP.
 Efforts should be made to improve the availability of IFA across the country.
4. a. Major findings of the studies conducted to evaluate Vitamin A prophylaxis
programme show that:
 Coverage levels of VA supplementation to the children are low due to
operational reasons like persistent shortages of vitamin A supplements and
poor logistics.
 There is poor community awareness about the importance of vitamin A.
 Evaluation of the impact of vitamin A supplementation on mortality and
morbidity shows no significant impact of VA on mortality and respiratory
tract infections among children.
b. Priority actions needed for improving the Vitamin A prophylaxis programme
are:
 There is a need of strengthening the VA supplementation programme
through promotion of consumption of foods rich in vitamin A in areas which
are found to be deficient in vitamin A.
 The programme should be strengthened through various measures like
improvement of community outreach, adequate training of functionaries,
provision of regular and adequate supplies of vitamin A supplements,
community participation and nutrition education and communication.
1. Reasons for limited impact of ICDS on nutritional status are:
 inadequate coverage of children below 3 years of age, of those at greatest
risk of malnutrition, and of women and children living in hamlets,
 irregular food supply, irregular feeding and inadequate rations,
 poor nutrition and health education of mothers (and none of families) to
encourage improved feeding practices in the home and other relevant
behavioural changes,
 inadequate training of workers,particularly in nutrition, growth monitoring,
and communication,
 anganwadi worker’s (AWW) overload, weak and unsupportive supervision
of AWWs resulting in the neglect of crucial nutrition-related tasks, and
 poor linkages between ICDS and the health system.
2. Priority actions needed to improve the ICDS programme are:
 improved targeting, especially to reach children under 2 years of age and
pregnant women who are most at risk of developing malnutrition,
 greatly enhanced quality of services and impact through better training and
supervision,
 establishing a reliable monitoring and evaluation system as soon as possible,
 community ownership and management of programme and, reducing AWW
overload and improving coverage of hamlets by either hiring a second
worker or separating the preschool education component from the rest of
the programme.
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3. Process and Impact evaluation of NSPE should include the following: Review of National
Nutrition
l The reactions of the key participants at the grass root level, namely the Programmes
schooler, the teacher and the local Ration Shop keeper about the programme.
l Linkages formed by the programme, if any, with the Primary Health Centre,
the Village Panchayats, and the ICDS.
l The positive and negative aspects of the NSPE versus Hot Meal Variant.
l Impact on nutritional status and cognitive development among the children.
4. The TPDS faces following criticism:
l It has been argued that a scale of ration of 20 Kgs per month per BPL
family is grossly inadequate since the average requirement of a family is
about 30 kgs per month The quantity of subsidized grain provided amounts
to a marginal supplement of 100 calories per person per day, far less than
the estimated gap of poor people in rural areas.
l Secondly, the PDS in most states still provides large quantities of subsidized
food to non-poor households, although this food could be targeted at needy
children and mothers, for example, through ICDS.
l It is unclear how the TPDS will plug leakages, particularly in the absence
of a rigorous monitoring system.
1. There are 3 main reasons which state why nutrition programmes taken together
have not been effective to combat malnutrition successfully in India. These are
poor implementation, inadequate coverage of BPL families and poor synergies
between programmes.
2. The priority actions required if we want to achieve the National Nutrition goals
by 2022 are:
 First, the country must put into place the leadership structure and administrative
capacity to ensure commitment to, and management of, the programmes
required to deal with the massive challenge. This encompasses the policy,
planning and implementation structure, and the institutional and individual
capacities necessary to make it work effectively.
 Second, the ICDS programme must greatly improve the quality of its
services, and their impact on vulnerable groups. Both the quality of services
and their impact must be regularly monitored and evaluated - and
improvements made continuously.
 Third, the health sector must give higher priority to malnutrition and ensure
that its actions have far greater impact on the problem than they do now.
 Fourth, India must do better at providing food security to the poor at the
community and household level. Sustained success in these four areas is
essential if India is to deal effectively with the crisis of malnutrition.
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Public Nutrition
UNIT 12 STRATEGIES TO COMBAT
PUBLIC NUTRITION PROBLEMS-I
Structure
12.1 Introduction
12.2 Strategies to Combat Public Nutrition Problems
12.3 Diet or Food-based Strategies
12.3.1 Dietary Diversification/Modification
12.3.2 Horticulture Intervention
12.3.3 Food Fortification
12.3.4 Nutrition and Health Education
12.4 Nutrient Based Approach : The Medicinal Approach to Combat Public Nutrition
12.4.1 Supplementation - A Short Term Preventive Strategy
12.5 Selecting/Implementing an Intervention Strategy
12.6 Let Us Sum Up
12.7 Glossary
12.1 INTRODUCTION
In Units 3 and 4, we learnt about the various public nutrition problems, their causes
and consequences. In Unit 10 we have discussed the on going nutrition programmes
of the country. In this and in the next unit we will learn about various strategies to
combat these public nutrition problems. We already know that there are multiple
causes of public nutrition problems. Therefore, we require multiple strategies to combat
these problems. In most instances, for maximal effectiveness, desirable control
programmes will include a variety of intervention strategies/approaches operating
concurrently and attacking various facets of the causative factors at the same time so
that the basic problems are being modified. What are these possible strategies? What
is the basis of these strategies? These are a few aspects covered in Unit 12. This Unit
will focus on the diet or the food-based and nutrient based strategies. The relationship
between immunization and malnutrition, genetics and biotechnology as one of the
strategies to combat malnutrition, role of clean water and sanitation to combat
malnutrition is the focus of Unit 13.
Objectives
After going through this unit you will be able to:
l highlight the various strategies to prevent malnutrition,
l differentiate between food-based and nutrient based strategies,
l describe the various food-based strategies namely, diet diversification, food
fortification, horticulture intervention, nutrition and health education, and
l discuss supplementation as a nutrient based strategy.
12.2 STRATEGIES TO COMBAT NUTRITION

PROBLEMS
PEM and micronutrient malnutrition are problems of global proportion. Micronutrient
268 malnutrition, as we have already studied earlier in Unit 3, is a term commonly used to
refer to vitamin and mineral deficiency diseases. Diets which lack adequate amounts Strategies to
of essential vitamins and minerals lead to such diseases. Vitamin A deficiency, iron Combating Public
Nutrition Problems-I
deficiency anaemia and iodine deficiency disorders are among the most common
forms of micronutrient malnutrition. Other micronutrients found in food, including
vitamins such as thiamin, niacin, riboflavin, folate, vitamins C and D, and minerals such
as calcium, selenium and zinc can also significantly affect health when dietary
deficiencies exist. Micronutrient deficiency is “hidden hunger” in that most people who
suffer from these deficiencies are not aware of that they are suffering from anything.
It has not been until quite recently that the scientific and public health community has
begun to understand the extent and impact of these public nutrition problems and
develop programs to combat them.
The primary causes of most micronutrient malnutrition are inadequate intakes of
micronutrient-rich foods and impaired absorption or utilization of nutrients in these
foods due to partly infection and parasitic infestation, which also increase metabolic
needs for many micronutrients. Poverty is often at the root of malnutrition and is also
linked to inadequate access to food, sanitation and safe water and to lack of
knowledge about safe food handling and feeding practices.
Recognizing this aspect, the Government of India’s Policy for control of public nutrition
problems currently combines both short, as well as, long term measures and recommends
a comprehensive strategy, addressing the following issues to achieve the goal of
improving the nutritional status of the population:
a) Diet/Food-based strategies viz. dietary diversification/modification, food fortification,
horticulture intervention, nutrition/health education,
b) Nutrient based strategy i.e. distribution of vitamin and mineral supplements.
c) Immunization programme in the context of public nutrition programmes.
d) Supplementary feeding programmes.
e) Improving the quality of food produced by genetic approaches.
f) Clean water and sanitation as a strategy to combat public nutrition problems.
g) Improving Food and Nutrition Security.
The strategies are not exclusive of the other; rather they are complementary and may
be of greater or lesser value according to present and changing circumstances. In fact
we need to understand that the public nutrition problems usually do not exist in
isolation, thus, a strategy for a given problem, area or a specific population would likely
incorporate many interventions - supplementation, fortification, dietary diversification,
as well as public health measures. The appropriate mix of interventions depends on
the specific context. Remember, there is NO ‘ONE-SIZE-FITS-ALL’ STRATEGY.
A review of these strategies is presented in this and the following unit. Here, in
this Unit the focus is on the food-based and nutrient based strategies. So let’s get
started.
12.3 DIET OR FOOD-BASED STRATEGY

Malnutrition, particularly micronutrient deficiency, usually occurs when diets lack
variety. Since the problem is mainly of dietary origin, it would perhaps be logical to
presume that policies/strategies need to be developed and implemented which ensure
year round access and consumption of an adequate variety and quantity of good
quality, safe food. Foods provide several essential micronutrients, simultaneously
addressing a combination of deficiency problems. Furthermore, physiological interaction,
between vitamin and minerals can enhance the body’s ability to absorb essential
micronutrients. It is in this context that diet or food-based approaches as preventive
strategies to combat malnutrition are gaining momentum. 269
Public Nutrition Food-based strategies are defined as a preventive and comprehensive strategy
that uses food (i.e. whole, refined form, processed, fortified or a combination) as
a tool to overcome micronutrient deficiency.
Diet and food-based approaches play an essential role in preventing micronutrient
malnutrition by increasing the availability and consumption of micronutrient-rich foods.
In the long-term, such approaches are more likely to be sustainable. However, you
would realize that the benefit of such approaches is not immediate. If overt micronutrient
malnutrition (such as xerophthalmia, goitre or cretinism, or severe iron deficiency
anaemia) is present, short-term supplementation programmes already discussed in Unit
10 would need to be implemented in addition to starting food-based activities. We will
look at the supplementation as a strategy to combat malnutrition later in this unit. Now
let us look at the benefits of food-based strategies. The benefits of food-based
strategies go beyond the prevention and control of micronutrient deficiencies. These
are highlighted in Box 1.
Box 1 Benefits of Food-based Strategies
The benefits of food-based strategies include:
l They are preventive, cost-effective and sustainable.
l They can be adapted to different cultural and dietary traditions and locally
feasible strategies.
l Because they are broad-based, aiming to improve the overall quality of the diet
of a population, they can address multiple nutrient deficiencies simultaneously.
l Because the amounts of nutrients consumed are within normal physiological
levels, the risk of toxicity is minimized.
l Food-based strategies support the crucial role of breastfeeding and the special
diet and care needs of infants and young children.
l Food-based approaches foster the development of sustainable, environmentally
sound food production systems. Agricultural planners are alerted to the need
to protect the micronutrient content of soils and crops.
l Food-based strategies build partnerships among governments, consumer groups,
the food industry and other organizations to achieve the shared goal of
overcoming micronutrient malnutrition.
Food-based approaches, therefore, are preventive, cost-effective and sustainable long-

term strategy to combat malnutrition, particularly the micronutrient deficiency. A
comparison of the cost-effectiveness of food-based programmes versus supplementation
has demonstrated that food-based approaches are preferable because they are
generally less costly, more sustainable, better able to target vulnerable groups and have
multiple nutritional benefits. Food-based strategies also promote sustainable improvement
by encouraging long-term behaviour changes. The modification of behaviour leading
to better selection or preparation of food so as to enhance intake or bioavailability of
nutrients is the primary goal of the approach. Few important food-based approaches
which can bring a qualitative improvement in the nutritional status include:
l Dietary diversification/modification to promote year round availability, access to
and utilization of foods which promote the increased intake and absorption of
nutrients
l Horticulture intervention including home gardening addressing issues of food
production, preservation, processing, marketing and preparation
l Food fortification to improve dietary intake of nutrients and their bioavailability
270 l Nutrition and Health Education to promote food-based approaches.
You may recall studying briefly about these food-based strategies earlier in Unit 3 Strategies to
under section 3.4 and 3.5 while studying about the nutritional deficiencies. A detailed Combating Public
discussion on these approaches is presented next in this unit.
12.3.1 Dietary Diversification/Modification

Dietary change or modification, as a food-based approach to improve nutritional
status is important. With respect to improving vitamin A status or iron status,
evidence suggests that dietary modification is the most cost-effective measure. Let
us see how?
Green leafy vegetables, we know, are the predominant sources of micronutrients for
all, particularly for the poor people. In India, for example, the prevailing vitamin A
malnutrition reflects the inadequate intake of these beta-carotene rich foods. Efforts
in combating vitamin A deficiency must therefore, be logically directed towards
augmenting the availability and intake of these relatively inexpensive foods. Abundant
sources of vitamin A exist. However, the contribution of such plants to alleviating
micronutrient deficiencies is greatly underappreciated. Among the wide range of green
leafy vegetables, drumstick leaves (Moringa oleifera) in particular provide a very
rich and inexpensive source of pre-formed vitamin A, in addition to other important
micronutrients. Native to India, the tree grows abundantly in all tropical countries
where vitamin A deficiency is a problem. A glassful of fresh drumstick leaves
contains the daily requirement of vitamin A for up to ten people, or small amounts of
less than 10 gm of fresh leaves can meet the day’s requirement of vitamin A of
preschool children. Hence advocating and implementing such dietary modifications can
go a long way in improving the vitamin a status of population groups.
Similarly, examples of relatively small modifications/changes in food behaviour/skills

which can have a significant impact on iron status are highlighted in Box 2.
Box 2 Examples of Relatively Small Changes in Food Behaviour/

Skills which can have a Significant Impact on Iron Status
CHILD FEEDING (New Behaviour)

l Feeding colostrum instead of discarding it
l Breastfeeding as long as possible, but not beyond the 2nd year
l Introducing complementary foods rich in iron at six months
l Providing small but frequent meals to the child
l Adopting a 5-6 meal pattern for infants/children
l Starting family food by one year of age
l Cooking food in iron vessels
l Introducing variety of food in the diet of infants
l Feeding items which inhibit or compete with iron absorption in between
meals rather than with meals: Milk with high calcium content may be
given in between meals or/and at bed time
GENERAL EATING HABITS

l Consuming iron-rich food more frequently. Infact including atleast one
source/serving of iron-rich food in each meal, if possible.
l Eating new food combinations to enhance iron absorption. Including
fruits (specially rich in vitamin C) with or directly after meals rather
than only between meals.
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Public Nutrition
l Consuming leaves or other part of the food that are not traditionally
consumed
l Avoiding or reducing the consumption of tea and coffee with meals
l Adopting practices such as fermentation/germination, where not practised
to increase the bioavailability of foods.
NEW SKILLS
l Preparation of recipes using higher proportion of iron-rich foods
l Appropriate household-level preservation methods for fruits, vegetables,
fish and meat
l Food preparation methods that preserve micronutrients i.e. short cooking
time, steaming, adding food to boiling water rather than cold water,
adding just enough water to aid cooking rather than cooking in large
amounts of water and draining excess water after cooking.
l Mashing and, if necessary, straining fruits and vegetables so they can be
eaten by infants.
* Adapted from FAO/IlSI 1997
The objective of dietary diversification is to ensure that individuals get essential

nutrients in sufficient amounts through their daily diet. The modification of the
behaviour leading to better selection or preparation of food so as to enhance
intake or bioavailability of these nutrients is the primary goal of this approach.
Dietary diversification to include more micronutrient rich food is an ideal and
sustainable long term solution. Improvements can be made, as you may have noticed
in the examples above, through the introduction of new crops, better cooking or food
a the home, better storage or preservation methods, improving food safety or the
promotion of more varied diets through nutrition education.
In adopting dietary diversification as a food-based strategy to prevent micronutrient
deficiency, certain steps have been suggested which are listed in Box 3.
Box 3 Steps in Adopting Diet Diversification/Modification as a Food-

Based Approach
The steps suggested in adopting diet diversification as a food-based approach

include:
l Assess what people are already eating, describing the daily meal pattern
- the foods/meals consumed and the items/dishes included therein - and
describing how dietary patterns are changing. Remember, food preparation
methods are culturally and economically determined and should be
approached with care and respect.
l Determine/analyse the bioavailability of the nutrient say availability of iron,
calcium etc. in the diet.
l Assess what can be modified with respect to:
— composition of meals (given the local food availability, cost and cultural
factors)
— food preparation
l Implement such modifications. For example frying and fermentation decrease
levels of beta-carotene in foods by about 25%; vitamin C is destroyed by
272
Strategies to
cooking. Losses of both beta-carotene and ascorbic acid are greatly reduced Combating Public
when vegetables are placed in boiling water and cooked for the minimum Nutrition Problems-I
time necessary. Steaming in a covered pan preserves nutrients even more
effectively.
l Assess the impact of approach i.e. in case of iron deficiency anaemia
reassess Hb levels (i.e. before and after improved practices)
Source: Adapted from WHO (1994)
Geared with the knowledge about how to adopt dietary diversification as a food-based
strategy, we must further understand that dietary change programmes may be more
sustainable at the family and community level when food sources are locally available
and have the advantage of providing other nutrients and dietary factors to improve
absorption and utilization of micronutrients. Dietary diversification, it must be noted, is
cheaper than any form of supplementation or fortification. First and foremost, it
requires a minimal amount of money, it promotes intakes of a whole range of
micronutrients rather than singling out and tackling just one, it is sustainable, it fosters
community and individual involvement, and can help stimulate local food economy.
Furthermore, this approach does not “medicalise” food and nutrition, rather it enables
individuals, families and communities to maintain their own health and nutrition. The
key to this solution lies in bringing about a shift away from the growing of just staple
crops, to a diversity of crops in the fields.
The “World Declaration and the Plan of Action on Nutrition”, adopted by 159
countries at the International Conference on Nutrition jointly organized by FAO and
WHO in 1992 states that strategies to combat micronutrient malnutrition should:
“Ensure that sustainable food-based strategies are given first priority particularly for
populations deficient in vitamin A and iron, favouring locally available foods and taking
into account local food habits.”
Furthermore, it pleads forcefully in its Plan of Action for a policy of:
“…promoting the dissemination of nutrition information and giving priority to breast
feeding and other sustainable food-based approaches that encourage dietary
diversification through the production and consumption of micronutrient-rich foods,
including appropriate traditional foods. Processing and preservation techniques allowing
the conservation of micronutrients should be promoted at the community and other
levels, particularly when micronutrient-rich foods are available only on a seasonal
basis.”
These statements are a clear call for the action that is urgently needed to promote
dietary diversification for the prevention and control of micronutrient deficiencies.
With a clear idea about the role of dietary diversification in combating public nutrition
problem, we move on to the next food-based strategy i.e. horticulture interventions.
12.3.2 Horticulture Interventions

Let us begin our study on horticulture intervention as a strategy to combat malnutrition
by considering the following case studies:
Case Study 1:Papaya saplings, drumstick trees and amaranth seeds were distributed
to mothers of preschool children, up to 30% of whom were landless,
living in South India. Local agricultural officers demonstrated how to
plant and care for the trees and beds of amaranth. The gardening
demonstration project raised the women’s awareness of the significance
of vitamin A-rich foods in their children’s diets.
273
Public Nutrition Case Study 2: Vegetable gardens (10 m plots) planted for a harvest sequence of
spinach- fenugreek-safflower-dock-amaranth-dill-amaranth-spinach
provided well over 100% of the recommended daily allowance for a
family of five. Harvesting the leaves early in the day and eating the
leaves within 3 hours after harvest provided the highest beta-carotene
intake (Josh and Aralkar 1994).
Having gone through these case studies, what can you conclude? Yes, any programme/
intervention that increases the production of micronutrient-rich foods is likely to have
a beneficial effect on the awareness and the micronutrient status of a population.
Horticulture inputs including home gardening addressing issues of food production,
preservation, processing, marketing and preparation are innovative measures targeted
to meet the goal of reducing the incidence of malnutrition and deficiency disorders.
Home gardening as a traditional family food production system is widely practised in
many homes and socities. FAO states that “the home garden is an important land unit
for households as it is often the center of family life; a well developed home garden
is a complete farming system; the home garden is the most direct means of supplying
families with most of the non-staple foods they need year-round. Home garden has
also been defined as a small-scale, supplementary food production system by and for
household members that mimics the natural, multi-layered ecosystem. Indigenous
gardens have been a part of household production systems since the beginning of
agriculture and remain important for food supply, nutrition and income in both
industrialized and developing countries.
Studies indicate that initiation of home gardens is possible and, if implemented
effectively, could have a comprehensive impact on community development, health,
nutrition and household food security in target populations. But, the use/effectiveness
of home gardening as a strategy to combat micronutrient deficiency in India is limited
to vitamin A deficiency control programmes. The Departments of Agriculture and
Social Forestry are making efforts in this direction. The Indian Council of Agricultural
Research (ICAR) has established 695 Krishi Vigyan Kendras or Farm Science
Centres so far in various parts of the country to impart training in agriculture
technologies to farmers. In the past, the major thrust was on cereal and millet
production. It is only in the recent years that horticulture production is receiving
emphasis. Women Extension Workers are trained not only in agriculture technologies,
but also in home gardening and preparation of recipes based on locally available
nutritious foods.
In our discussion above so far we have focussed on home gardens. Besides home
gardening, community and family vegetable and fruit gardens play a significant role in
increasing small-scale production of micronutrient-rich foods. School-based gardening
programmes can be an excellent means of introducing new ideas about gardening and
a useful channel for reaching others in the community, as children tend to be more
open than adults to the adoption of new ideas. School-based programmes can reduce
micronutrient malnutrition by:
l promoting consumption of fruits and green leafy vegetables,

l teaching students how to establish and maintain home gardens,
l introducing students to food preparation and storage techniques,
l providing nutrition information and encouraging adolescent girls to adopt more
healthful dietary habits before their first pregnancy, and
l enhancing the status of and students’ interest in agriculture and nutrition as future
occupations.
A successful example of school gardening project is illustrated in Box 4
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Strategies to
Box 4 Successful Gardening Promoted Through Schools - the Asian Combating Public
Vegetable Research and Development Centre Case Study Nutrition Problems-I
A model school garden project in Taiwan developed a 10 × 18 m school garden

that provided half a cup of vegetables per day for each of 142 children throughout
the school year, using indigenous plants. Each garden consisted of 12 raised beds
that over the course of the year contained four or five vegetables. Garden
produce provided an estimated 58% of the daily vitamin A requirement and 285%
of the daily vitamin C requirement for a 10-year-old child.
Having gone through the discussion above it must be evident that if planned and
designed with a good understanding of local circumstances, gardening is an effective
food-based approach to improving micronutrient status. A variety of micronutrient-rich
crops can be grown by making use of available space, soil, water and microclimates.
Gardening can be promoted at the household or community level or at schools.
Programmes that promote small-scale production of micronutrient-rich foods can
mobilize communities by appealing to community members’ perceived needs (e.g., to
increase food supply or generate income) in addition to offering to improve nutritional
quality of the local food supply. Women are often more interested than men in working
in such community projects, and their involvement can improve their income and social
status. Even more important, children’s nutrition benefits the most when women retain
control of income generated by community projects.
With this we end our study of horticulture intervention, we move to the next important
food basd strategy i.e. fortification. But first let us recall what we have learnt so far.

1. Enumerate the strategies, which can be adopted to achieve the goal of
improving the nutritional status of the population.
..........................................................................................................................
..........................................................................................................................
2. What are food-based strategies? What are their benefits?
..........................................................................................................................
..........................................................................................................................
3. Discuss the role of dietary diversification in combating public nutrition problem.
..........................................................................................................................
..........................................................................................................................
4. ‘Home gardening is an effective food-based approach to improving micronutrient
status’. Comment on the statement giving appropriate examples.
..........................................................................................................................
..........................................................................................................................
Continuing with our study on food-based approached, we now move on to fortification

as a strategy to combat malnutrition.
12.3.3 Food Fortification

The addition of nutrients to foods in order to maintain or improve the nutritional quality
of individual foods or the total diet of a group, a communuity or a population is referred
to as food fortification. As per the Food Safety and Standard Authority of India 275
Public Nutrition notification (FSSAI, 2018), fortification means deliberately increasing the content of
essential micronutrients in a food so as to improve the nutritional quality of food and
to provide public health benefit with minimal risk to health. Fortification as defined by
the Codex Alimentarius is “the addition of one or more essential nutrients to a
food, whether or not it is normally contained in the food, for the purpose of
preventing or correcting a demonstrated deficiency of one or more nutrients in
the population or specific population groups”.
While studying about fortification, you may come across other terminologies such as
fortificants, fortified food. What are these terms?
‘Fortificant’ means a substance added to food to provide micronutrients but does not
include nutraceuticals or food for Specific Dietary Uses.
‘Fortified Food’ means a food, as specified under the Food Safety and Standard (Food
Product Standards and Food Additives) Regulations (2011),that has undergone the process
of fortification as per the provision of these regulations.
Having looked at these terms can you now illustrate one example of food fortification
in our country. Yes, the iodization of salt is a classical example of food fortification.
Extensive tests, using iodine fortified salt in the community, have demonstrated the
effectiveness of the fortified salt in improving the iodine status and reducing the
prevalence of iodine deficiency disorders.
Specific benefits of food fortification include the following:

l It can provide wide population coverage. Combined nutrient fortification can
address multiple deficiencies.
l It encourages industries to be socially concerned and to add nutritional value to
their products. It provides opportunities for consumers to become involved in food
quality issues and creates demand for safe, wholesome food.
In developing countries, fortification is increasingly recognized as an effective medium-

and long-term approach for improving the micronutrient status of large populations.
Fortification does not require changes in the dietary habits of the population, can often
be implemented relatively quickly and can be sustainable over a long period of time.
It is considered by World Bank, as one of the most cost-effective means of
overcoming micronutrient malnutrition.
So, then what is the philosophy behind the addition of nutrients to food? Is it purely
nutritional considerations or are other factors involved? Basically essential nutrients
are added to foods for the purposes of contributing to any of the following:
a. Preventing or reducing the risk of, or correcting, a demonstrated deficiency of one

or more essential nutrients in the population or specific population group;
b. meeting requirements or recommended intake of one or more essentials nutrients;

c. maintaining or improving health;
d. maintaining or improving the nutritional quality of foods.
Harris has described six distinct philosophies of food fortification which are reviewed
herewith:
1. Fortification for restoration to normal level: We have read above that

nutrients can be removed or destroyed in food processing or storage. Under such
circumstances, fortification may be undertaken for addition of nutrients to replace
those removed or destroyed.
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2. Fortification above normal level: Addition of nutrients to certain foods for
Combating Public
special dietary uses is allowed. In special purpose foods i.e. foods for infants or Nutrition Problems-I
geriatric food or foods for use in weight reducing diets, nutrients may be added
in quantities well above the natural level with the intention of supplying the total
nutrient requirements in the minimum amount of food consumed, perhaps in a
normal daily portion of the particular food.
3. Enrichment with public health objective: Fortification of salt with iodine is in
fact a classical example of enrichment with public health objective. Food or series
of foods as a vehicle is used for distributing nutrient supplement linked to a
demonstrable need for these nutrients in the population or in a particular segment
of the population.
4. Enrichment of ‘substitute’ foods to equivalent nutrient level: With advancements

in food science and technology, new products are being developed as alternates
to natural products. A need has risen to ensure that these foods supply equivalent
amount of important nutrients. This is where fortification assumes importance.
The fortification of margarine with vitamin A is an example of this kind of
fortification.
5. Fortification to make a food complete in itself: Under this philosophy, each

food might contain adequate amount of the nutrient required for its metabolism.
For example, suitable quantities of group B vitamins might be added to sugar or
other heavily sweetend foods to provide for the demand of carbohydrate
metabolism.
6. Addition of nutrients for non-nutritional purposes: You may recall studying

about the use of carotene, riboflavin etc as natural colouring matter in foods.
Similarly the addition of ascorbic acid, vitamin E etc. as antioxidants is prevalent.
Addition of nutrients for technological reasons as mentioned above is the
philosophy here.
With these philosophies in mind we can now appreciate the importance and scope of
food fortification. However, for maximum effectiveness of this strategy certain basic
criteria should be satisfied. These include:
l There should be a demonstrated need for a nutrient in one or more population

groups
l Food selected as a vehicle for the nutrient(s) must reach the population at risk
l The amount of nutrient added to food will supply adequate intake when the food
is consumed in normal amounts by the population at risk
l The amount of nutrient added will not be toxic or harmful to individuals with a high
intake of the fortified food
l The nutrient is biologically available in the form in which it is added and is stable
in the food selected as a vehicle
l The food selected does not seriously interfere with the utilization of the nutrient
l Addition of the nutrient has no detrimental effect on flavour, shell-life, colour,

texture or cooking properties of the food
l Fortification is technically feasible for the particular food
l The cost of fortification does not result in a significant change in the cost of food
l A method of controlling and/or enforcing the level of fortification is available

277
Public Nutrition Selection of the carrier for fortification is a critical step and several required
characteristics of the carrier have been noted. The identified vehicle must be
consumed in roughly constant quantities throughout the year by the majority of the
population. The food must pass through a centralized point to facilitate a rigidly
controlled fortification process. The addition of fortificants at the required levels
must not affect the organoleptic qualities of the food. Thus if a fortifiable food
exists that is consumed by many people at risk of developing a deficiency/
malnutrition, fortification is likely to be the most cost-effective component of any
control programme.
Considering these aspects various carriers for fortification and standards for fortification
of food products have been provided by FSSAI (Food Safety and Standard (Fortification
of Foods) Regulations, 2017). These include:
1. Fortification of Salt with Iodine
Salt shall be fortified with iodine and may also be fortified with iron in combination
with iodine, at the level given in the Table 12.1:
Table 12.1: Standards for Fortification of Salt with Iodine
S.No. Components Level of Nutrients
1. (a) Manufacture level Not less than 30 parts per million on dry
weight basis
(b) Distribution channel including Not less than 15 parts per million on dry
retail level weight basis
2. Iron content (as Fe) 850-1100 parts per million
2. Fortification of Vegetable oil with Vitamin A or Vitamin D

Vegetable oil may be fortified with the following micronutrients, singly or in
combination at the level given in the Table 12.2:
Table 12.2: Standards for Fortification of Vegetable oil with Vitamin A or
Vitamin D
S.No. Nutrients Minimum Level Source of Nutrients
of Nutrients
1. Vitamin A 25 IU per gm of oil Retinyl acetate, Teinyl
palmitate and Retinyl
propionate
2. Vitamin D 4.5 IU per gm of oil Cholecalciferol and
ergocalciferol
3. Fortification of Milk with Vitamin A or Vitamin D
Standardized, tonned, double tonned or skimmed milk may be fortified with the
following micronutrients, singly or in combination, at the level given in Table 12.3.
Table 12.3: Standards for Fortification of Milk with Vitamin A or Vitamin D
S.No. Nutrients Minimum Level of Nutrients Source of Nutrients
per liter of tonned/double
toned/skimmed milk
1. Vitamin A 770 IU Retinyl acetate, Retinyl
palmitate and Retinyl
propionate
2. Vitamin D 550 IU Cholecalciferol and
ergocalciferol
278
4. Fortification of Vanaspati Strategies to
Combating Public
Vanaspati, shall be fortified with the following micronutrient at the level given in the Nutrition Problems-I
Table 12.4.
Table 12.4: Standards for Fortification of Vanaspati
S. No Nutrients Level of Nutrients
1. Synthetic Vitamin A Not less than 25 IU per gm at the time of
packing. Should be test positive when
tested with Antimony Trichloride (Carr-
Price Reagent) as per IS:5886-1970
5. Fortification of Atta
Atta, when fortified, shall contain added iron, folic acid and vitamin B12 at the level
given in the Table12.5:
Table 12.5: Standards for Fortification of Atta
S. No. Nutrients Minimum Level of
Fortification per Kg
1. Iron-Sodium Iron (III) Ethylene diaminetetra
acetate, Trihydrate (Sodium federate-Na Fe EDTA) 20 mg
2. Folic acid 1300 µg
3. Vitamin B12- hydroxycobalamine; 10 µg
6. Fortification of Maida
Maida, when fortified, shall contain added iron, folic acid and vitamin B12 at the
level given in Table 12.6.
Table 12.6: Standard for Fortification of Maida
1. Iron –(a) Ferrous citrate, Ferrous lactate, Ferrous 60 mg
sulphate, ferrous pyrophosphate, electrolytic iron,
ferrous fumerate
(b )Sodium Iron (III) Ethylene diamine tetra
acetate, Trihydrate (Sodium federate-Na Fe EDTA) 20 mg
3. Vitamin B12- hydroxycobalamine; 10 µg
7. Fortification of Rice
Rice, when fortified, shall contain added iron, folic acid and vitamin B12 at the level
given in Table12.7.
Table 12.7: Standards for Fortification of Rice
1. Iron-(a) Ferric pyrophosphate(b)Sodium 20 mg
Iron (III) Ethylene diamine tetra acetate,
Trihydrate (Sodium federate-Na Fe EDTA)
3. Vitamin B12- cynocobalamine, hydroxycobalamine; 10 µg
279
Public Nutrition In addition, Atta, Maida and Rice may also be fortified with the following micronutrients,
singly or in combination, at the level given in Table 12.8.
Table 12.8: Standards for Fortification of Atta, Maida and Rice with
Micronutrients
Fortification
1. Zinc- zinc sulphate 30 mg
2. Vitamin A- Retinyl acetate, Retinyl palmitate and
Retinyl propionate 1500 µg RE
3. Thaimine (Vitamin B1)- Thaimine hydrochloride,
Thaimine mononitrate; 3.5 mg
4. Riboflavin (Vitamin B2)-Riboflavin, riboflavin 5’-
phosphate sodium; 4 mg
5. Niacin-Nicotinamide, Nicotinic acid; 42 mg
6. Pyridoxin (Vitamin B6)-Pyridoxine hydrochloride; 5 mg
With respect to infants and young children, who are undoubtedly vulnerable, for a
number of reasons, fortification of complementary foods is positively one important
preventive strategy for iron deficiency. More recently, multiple fortifications - fortifying
wheat flour and other selected food items with nutrients like iron and B-Complex
vitamins has also been suggested for our country. Fortification with two micronutrients
(e.g. iron and vitamin A or iron and vitamin C) would enhance the effect of
fortification on micronutrient status. This is particularly important with respect to
infants/young children, in whom the prevalence of multiple nutrient deficiencies
is high.
Fortification is being promoted through both, the open markets and the government
safety net programme, such as Integrated Child Development Scheme (ICDS), Mid-
Day-Meal Scheme (MDM) and Public Distribution System (PDS). It is estimated that
through the ICDS and MDM programme, benefit of food fortification could reach 18
crore beneficiaries. As the beneficiaries are provided with only one meal through the
safety net programme, the consumption of these fortified products will ensure in meeting
30-50 percent of RDA along with dietary diversifications.
Although, fortification may be effective without consumer education, it is generally

considered wise to include a consumer education component, only to avoid incorrect
information. Education may also be required when the fortified product requires
different handling during household storage and when certain cooking or product use
practices result in loss of the fortificant. A logo for consumer in identifying fortified
staples known as the ‘‘+F’’ logo.
Further, educational programmes may be required along with food fortification,

particularly if (i) the fortification causes any change in the flavour, appearance,
cooking properties, or cost of the food, (ii) there is a danger that the home treatment
of the food may remove or destroy the added nutrient. For example, some people may
be accustomed to washing impure salt before using it. If salt of this kind is iodized,
consumers must be educated not to wash it because washing will remove all the
iodine, or iii) the programme depend on the addition locally of a centrally prepared
premix. iv) packaging and labeling requirements, under this following points are need
to be taken into consideration while packaging the fortified food products: a) All
fortified food shall be packaged in a manner that takes into consideration the nature
of the fortificant added and its effect on the shelf life of such food. b) Every package
of fortified food shall carry the words “Fortified with….(name of the fortificant)” and
the logo, as specified above. c) Every package of food, fortified with Iron shall carry
a statement “Not recommended for people with Thalassemia and people on low iron
280 diet”.
With this we end our study on fortification. You would realize that the success of food- Strategies to
based strategies lies in effective nutrition communication. How nutrition communication Combating Public
can promote food-based strategies, is the focus of the next section.
12.3.4 Nutrition and Health Education

In our discussion above we have highlighted that diet diversification, agricultural
production of micronutrient-rich foods and production of micronutrient-fortified processed
foods enhance micronutrient availability. However, achieving increased consumption of
these foods may require a change in food habits. This is not easy. Such a change
requires a vigorous and concerted effort through a variety of communication channels,
e.g., radio/television, print media and interpersonal communications. Nutrition
communication, can be a powerful force in helping individuals make sound decisions
about what they purchase, grow and eat. There is conclusive evidence that nutrition
communication can convey information, help people develop necessary skills and
motivate people to make lifestyle changes. Evidence from India indicate that nutrition
communication alone without any other input can be a promising approach for bringing
about improvement in dietary behaviour. Nutrition education can convey information,
persuade individuals to consume food rich in micronutrients, choose fortified foods,
and prepare food in new ways to protect their nutrient content and change patterns
of feeding children.
So then what is nutrition communication or nutrition education? Nutrition Education

is that group of communication activities aimed at achieving a voluntary change
in nutrition-related behaviour to improve the nutritional status of the population
(FAO).
The Government of India’s policy for control of nutritional anaemia, for example,
includes Nutrition /Health Education as one of the major long-term measures to
prevent iron deficiency. The National Consultation on Control of Nutritional Anaemia
(GOI 1998) recommended that the existing Nutritional Anaemia Control Programme
should be comprehensive and incorporate Nutrition Education through school health
and ICDS infrastructure to promote:
l regular intake of iron/folic acid-rich foods by all age groups
l consumption of foods that increase absorption of iron and vitamin C and avoid
foods which inhibit iron absorption (tea/coffee), and
l adequate availability of iron-rich foods by:

— increasing their production through development of kitchen gardens in
homes, schools and the villages
— development of iron fortified foods and promoting their consumption.
Based on these guidelines the key messages to promote good iron status among
children through diet diversification/modification have been identified and highlighted in
Box 5.
Box 5 Key Nutrition Messages to Improve Iron Status
l Breast feed the child exclusively for 0-6 months

l Introduce complementary food at 6 months of age
l Ensure adequate inclusion of iron and vitamin A/C-rich food or foods
fortified with iron in the household diet
l Provide lots of green leafy vegetables such as mustard, fenugreek, bathua,
spinach and corriander etc. 281
Public Nutrition
l Avoid serving tea/coffee along with meals (atleast 2-3 hours before or
after a meal)
l Serve a glass of fresh lemon juice along with meals rather than tea/coffee.
l Add a few drops of lemon juice in dal/vegetable preparations.
l Cook food in iron pots/kadhai. This will provide the much needed iron to
keep the body healthy
l Include flesh foods (meat, poultry, liver, fish) in the diet, whenever possible
l Use fermented and sprouted foods such as sprouted pulses
l Wash raw foods thoroughly before eating or serving to children
l Remove milk from the meal and serve it between meals or at bed time.
Adapted from GOI (1996), WHO (1994)
Experiences have shown that the most successful behaviour-change nutrition education
projects are based on systematic planning. A theoretical framework for planning
nutrition education interventions has been proposed by Adrien and co-workers. The
framework highlights four phases - conceptualization, formulation, implementation and
evaluation - as its components which are described later in Unit 15 in this course
booklet. Planning a nutrition education intervention to prevent micronutrient deficiency,
would require consideration on the following issues:
l What are the factors contributing to the micronutrient deficiency?
l Which food or food-related behaviour to promote or change?
l Who does the message need to reach?
l How should the message be presented?
l What communication channels should be used for maximum impact?
A detailed discussion on these aspects and other issues related to nutrition and health
education is presented later in Units 15-18. Hence, we shall not go into the details here
in this unit.
What we must emphasize here is that any nutrition communication programme should
aim to reach the wider population. For example, a communication campaign that aims
to improve micronutrient intake in young children must be directed at the children’s
care-givers. Besides the mothers, caretakers, or those who prepare families’ food and
supervise the feeding of children it is also important that those who make decisions and
shape opinions about food consumption patterns in the household are included in the
campaign. In any community, religious, traditional and cultural leaders can influence
shifts in food behaviour and sanction new customs. In certain regions, fathers do the
shopping and control the money used to buy food. In many cultures, the father decides
what food is served in the household and how it is apportioned. For these reasons,
targeting messages only at mothers, caregivers may be ineffective. It is also important
to provide nutrition education for school children, girls out of school and adolescents,
as they are future parents and need to be aware of how to maintain or improve their
dietary habits.
From our discussion above you may now be able to appreciate the role of nutrition
and health education in improving the nutritional status of community groups. But, it
must be emphasized here that for any nutrition communication programme to be
effective and to bring about a lasting change it must focus on exposing the target
282 population to the messages and on the retention of the message on the part of the
audience. A long term carefully sequenced communication effort is necessary to Strategies to
achieve permanent change in food behaviour. Repeated exposure to the message is Combating Public
extremely crucial for long lasting effects. Specialists in public health communication
have noted the phenomenon of behaviour decay, or reversion to an original behaviour
pattern in the absence of periodic reinforcing messages. Experiences from the
Expanded Food and Nutrition Education Programme (EFNEP) in USA indicate that it
may take years for the desired changes in behaviour to become sustained. Hence
nutrition and health education is a long term strategy, but can be an effective strategy
to combat the public health problems.

1. What is food fortification? Explain giving appropriate examples.
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2. Enumerate the philosophy behind using fortification as a strategy to combat
public nutrition problems.
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3. List the basic points one should keep in mind for ensuring maximum effectiveness
of fortification as a strategy to combat malnutrition.
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4. ‘Nutrition communication, can be a powerful force in helping individuals make
sound decisions about what they purchase, grow and eat’. Justify the statement
using appropriate examples.
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..........................................................................................................................
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Having studied about the food-based strategies, let us move on to the nutrient based
strategy, i.e. supplementation as a strategy to prevent malnutrition.
12.4 NUTRIENT-BASED APPROACH: THE

MEDICINAL APPROACH TO COMBAT
PUBLIC NUTRITION PROBLEMS
As compared to the food-based approaches, the medicinal approach - is a drug-based
approach to combat public health problems. Nutrient supplements are effective. The
medicinal approach, which is cheap in terms of cost of the pills, but expensive in terms
of the support devoted to repetitive use of scarce health-manpower, has been
successful in reducing clinical deficiency signs. To illustrate, countries like Indonesia,
as well as, Vietnam have declared themselves to be free of clinical vitamin A
deficiency (Xerophthalmia) in part because of the successful broad coverage 283
Public Nutrition achieved through periodic delivery of high-dose vitamin A supplements. In the
previous unit we have learnt about supplementation as a strategy to combat public
nutrition problems. In this section however, we will recapihilate these strategies.
What is the strategy? What are its potentials and drawbacks? Under what circumstances,
the strategy is likely to be beneficial? These are a few issues highlighted in this section.
So let us get started.
12.4.1 Supplementation - A Short Term Preventive Strategy

Supplementation as a short term strategy to prevent micronutrient deficiency particularly,
iron and vitamin A deficiency, is most common in many countries. The oldest
intervention route has been the provision of daily oral iron supplement. At the time
of its introduction, supplementation was thought of as a short term emergency
measure. But most of the current strategies worldwide still rely heavily on health
interventions - usually the administration, at periodic intervals, of oral dosages of
synthetic vitamin/mineral supplements to children under three years of age. This was
pioneered in India in the late 1960’s . What was originally envisaged as a temporary
and short-term measure, and an adjunct to dietary improvement of communities in
India, became the default model for current programs to eliminate some of the
common public health problems like VAD.
Single-nutrient supplementation targeted at specific population groups has become an
increasingly popular strategy to combat micronutrient malnutrition. You may recall
studying about supplementation as a strategy to combat iron deficiency anaemia,
vitamin A deficiency etc. earlier in Unit 10. The Government of India, you learnt , has
launched the vitamin A supplementation programme on a national scale and the
‘National Nutritional Anaemia Control Programme’ to prevent and control nutritional
anaemia. Under these programme, the schedule of supplementation recommended for
preventive/therapeutic supplementation for population groups is highlighted in Table
12.9. This population-based approach is a pragmatic response to limited resources and
assumes that, within a targeted group, the diagnosis of the nutrient deficiency is secure,
its prevalence is clinically significant, and the benefits of supplementation outweigh the
risks.
Table 12.9: Supplementary doses of nutrients recommended for
preventive/therapeutic supplementation
Nutrient Target Group Schedule of Supplementation

Iron Infants (6-60 months) 1 ml of IFA Syrup containing
20 mg of elemental iron and
100 mcg of folic acid.
Children (5-10 years) - 45 mg of elemental iron and
400 mcg of folic acid
Old Children (10-19 years) - 100 mg of elemental iron and
500 mcg of folic acid
Pregnant Women and - 100 mg of elemental iron and
Lactating Mothers 500 mcg of folic acid
Women in Reproductive - 100 mg of elemental iron and
Age (WRA) group 500 mcg of folic acid
Vitamin A Infants 6-11 months of age - 100,000 IU of vitamin A
Children between the age 200,000 IU of vitamin A
1-5 years (currently only) given once every 6 months
Iodine Women and children in - Iodized oil injection -

hyper-endemic areas Single dose of 1 ml
(Children between 1-3 yrs. old)
284
The evidence is indisputable that supplements can substantially reduce the micronutrient Strategies to
deficiency. However, it is to be noted that supplementation, as a strategy, cannot Combating Public
correct a basic inadequacy in the quantity of food. The circumstances in which
supplements may, therefore, be useful are limited and these are outlined herewith:
l Supplementation as a therapy of specific deficiency and other diseases :
As discussed above, supplementation may be needed to treat nutritional
deficiency diseases prevalent in an area. For example providing folifer tablets
to all pregnant women for prevention of anaemia. Further, diseases causing
malabsorption or excessive loss of nutrients may lead to secondary malnutrition;
the classic example is the role of hookworm infections in causing iron deficiency
anaemia. Under such circumstances, the administration of appropriate therapeutic
levels of iron would be a necessary part of therapy.
l Part of a broad preventive programme in the face of demonstrated need:
If it is apparent that a particular deficiency disease is prevalent in a population,
provision of suitable supplemnt is indicated as a measure to effect rapid
improvement. Under such circumstances waiting for a broader programme of
nutrition/health education and food supply may not be very appropriate. However,
it must be realized that supplementation should be used in conjunction with,
but not as an replacement for, improvement in food selection.
l Complement to feeding programmes: Certain situations indicate a need for
nutrient supplement. For example, you may recall studying that under many
circumstances, the government resorts to provision of food supplements.
However, in areas where it is apparent that a particular deficiency disease
is prevalent, it may be strongly recommended that in these areas the food
source may be fortified with the particular nutrient. However, if a suitable
fortified source is not available, then it is clearly expedient to supply the
nutrient supplemnt along with the food source. This is how supplementation
complements the feeding programme.
Supplementation as a short term strategy, therefore, can be effective. However,
long experience with this intervention shows that it does not always work. The
reasons identified, contributing to its ineffectiveness include: lack of compliance,
economic constraints, poor efficiency of health services, dose-related undesirable
gastrointestinal side effects, poor coverage, lack of awareness by local health workers,
poor quality of supplement tablets etc. This ‘drug-based approach’ to synthetic
vitamin A distribution has received wide criticism, even from the very individuals
who have pioneered the work. Some of the limitations cited based on the 30-year
experience of India are: ineffectiveness in correcting VAD (especially in populations
where milder signs of deficiency are widespread), the limited shelf-life of vitamin
A, and logistical problems in ensuring supply.
Supplementation programs are often expensive and unsystematic, and coverage may
be poor. Frequently, the key target groups are different for each micronutrient, and
operational constraints are severe. Further, the ease of supplementation has meant
neglection of research into and promotion of better use of inexpensive food sources
and diet diversification as a lasting long term strategy to prevent public nutrition
problems.
With our discussion above we end our study of different strategies. Next, we shall
learn how to implement an intervention strategy.
12.5 SELECTING/IMPLEMENTING AN
INTERVENTION STRATEGY
Having read about the different food and nutrient based strategies, the crucial question
that need to be addressed next is which of these strategies, is the most appropriate.
Well, this is a difficult question to answer. As mentioned earlier, there is really NO
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Public Nutrition ONE-SIZE-FITS-ALL STRATEGY. Several approaches exist, as we now know,
and also highlighted in Table 12.10, to prevent and treat malnutrition, each with its own
strengths and limitations (refer to Table 12.11), but which are highly effective if
applied in complementary ways. The appropriate mix of interventions will depend on
the specific context.
Table 12.10: Approaches to prevent micronutrient deficiencies
Dietary Food Supplementation Public Health

diversification Fortification Measures
Sea foods reduce Salt Iodized oil, Legislation

Iodine
goitrogens Water Potassium iodide Enforcement
deficiency
Baby foods tablets Salt monitoring
disorders
Condiments Primary health care
Flour
Milk
Green leafy Sugar Capsules (oil) in Prevention of

Vitamin A
Vegetables Salt massive or small infections:
deficiency
Orange Milk powder doses -- immunization
Fruits/vegetables Baby foods -- antiparasitics
Red palm oil Condiments -- environmental
Animal foods health
Breast milk
Green leafy Salt or Iron/folate tablets Prevention of

Anaemia
Vegetables Cereals Parenteral iron infections
Pulses Flour -- Immunization
Fruits/vegetables Condiments -- Antiparasitics
(vitamin C) -- Environmental
liver, red meat health
Avoid tea/coffee
with meals
There are several points to consider in selecting/implementing an intervention strategy.

These are illustrated next:
l Epidemiologic considerations:
 prevalence of the specific micronutrient deficiency
 severity of the specific micronutrient deficiency
 geographic extent/clustering of the micronutrient deficiency
 whether specific groups or subgroups are affected
 cause of the deficiency (single, multiple)
l Level of country development: This aspect for example will influence the
selection of strategies like food fortification which entails that food processing
facilities, preferably centralized, must exist.
l Capacity of country to implement and sustain the intervention
l Cultural considerations
 typical diet
286  symbolic, ceremonial meaning of food/meals

Circumstances in which the various interventions may be appropriate in Strategies to
conjunction with advantages and disadvantages of the main interventions are presented Combating Public
in Table 12.11.
Table 12.11: Interventions - appropriateness, advantages and disadvantages

Intervention Appropriate for: Advantages Disadvantages/
Challanges
Supplementation Therapeutic treatment Timely More costly than

Prevention programmes Sustainability other measures
(target groups) Narrow scope of coverage
Fortification Prevention (Universal) Highly cost Requires participation of

effective food industry
Wide coverage Does not lead to
sustainable awareness building and
changes in wider dietary
habits
Dietary Prevention (Universal) Highly cost Requires changes in

Diversification effective eating behaviour
Wide Coverage Requires economic
sustainable development to be
feasible
Require change in
agricultural policies
An important advantage of food-based strategies is that foods provide many

micronutrients simultaneously. Food-based approaches (i.e. fortification and dietary
diversification) have the additional benefit of integrating micronutrient control
programmes. And, interactions are avoided between potential concentrated-
dose supplements. The long-term goal of intervention should be to shift away from
supplementation (which may be appropriate in the short-term for dealing with severe
deficiency) toward a combination of food fortification and dietary diversification.
In other words, as the population prevalence and level of severity for a given
deficiency decreases, the intervention mix should favour food-based approaches.
Having gone through the strengths and limitations, you would agree that an appropriate
mix of interventions depending on the specific context should be considered. Although
the three major micronutrient deficiencies have many different causes and potential
solutions, opportunities exist to coordinate micronutrient deficiency control programmes.
The advantages of programme coordination include:
l reductions in costly duplication,
l avoidance of unconstructive competition for funding (for example, joint grant
applications may increase the likelihood of obtaining funding for all programmes),
l opportunity for combined information, education and communication efforts.
l opportunity for holding joint training sessions, and
l an increased likelihood of reaching policy makers with effective messages.
However, to be efficient and effective, strategies must incorporate a means of
programme monitoring such that ongoing feedback occurs and programmes are
improved in response to feedback.
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Public Nutrition
1. Supplementation as a short term strategy is effective to combat malnutrition.

Comment on the statement giving appropriate justifications.
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2. Enumerate the limitations of adopting supplementation as a strategy to combat
malnutrition.
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3. What points would you consider in selecting/implementing an intervention
strategy?
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12.6 LET US SUM UP

Various strategies can be adopted for the prevention of public nutrition problems
prevalent in our country. In this unit we studied about the food-based and the nutrient
based strategies to prevent malnutrition. Among the food-based strategies, diet
diversification, fortification, horticulture intervention and nutrition and health education
were covered. We studied that these food-based strategies are the most cost effective
means to tackle the public health problems and are in fact the long term measures. As
compared to the food-based strategies, supplementation is the medicinal approach, to
combat the public nutrition problems. Supplementation as a short term strategy to
prevent micronutrient deficiency particularly, iron and vitamin A deficiency, is most
common in many countries. But, it has various limitations. Therefore when we talk
about strategies, an appropriate mix of interventions, namely diet diversification,
fortification, horticulture intervention, nutrition and health education, supplementation
may be considered, depending on the specific context.
12.7 GLOSSARY
Intramuscular Injection : Injection of medicines into muscle for treatment of
disease.
Malnutrition : Condition occuring due to deficiency or excessive intake
of nutrients.

EXERCISES
1. The strategies which can be adopted to achieve the goal of improving nutritional
status are:
l Diet/ Food-based strategies viz. Dietary diversification/ modification, food
fortification, horticulture intervention, nutrition., health education.
l Nutrient based strategy i.e. distribution of vitamin and mineral supplements.
288
l Immunization programme in the context of prevention of public nutrition Strategies to
programmes. Combating Public
l Supplementary feeding programmes.
l Improving the quality of food produced by genetic approaches.
l Clean water and sanitation as a strategy to combat public nutrition problems.
l Improving food and nutrition security.
2. Food-based strategies are preventive and comprehensive strategy that uses food
(i.e. whole, refined form, processed, fortified or a combination) as a tool to
overcome micronutrient deficiency,
The benefits of food-based strategies include
 They are preventive, cost effective and sustainable.
 They can be adapted to different cultural and dietary traditions and
locally feasible.
 As they are broad based, aiming to improve overall quality of the diet of a
population, they can address multiple nutrient deficiencies simultaneously.
 Since the amounts of nutrients consumed are within normal physiological
levels, the risk of toxicity is minimized.
 Food-based strategies support the crucial role of breastfeeding and the special
diet and care needs of infants and young children.
 Food -based approaches foster the development of sustainable, environmentally
sound food production systems. Agricultural planners are alerted to the need
to protect the micronutrient content of soils and crops.
 Food-based strategies build partnerships among government, consumer groups,
the food industry and other organization to achieve the shared goal of
overcoming micronutrieint malnutrition.
3. The role of dietary diversification is to ensure that individuals get essential nutrition
in sufficient amounts through their daily diet. Better selection or preparation of food
so as to enhance intake or broad availability of these nutrients is the primary goals
of this approach.
4. Home gardening is an effective food-based strategy if implemented effectively,
could have an impact on community development in Health and Nutrition. Home
gardening as a strategy is limited to combat vitamin A deficiency as vitamin A/
carotene rich green-leafy vegetables cultivation can be promoted through this
method.a
1. Food fortification is defined as the addition of one or more essential nutrients to a
food, whether or not it is normally contained in the food for the purpose of
preventing or correcting or demonstrated deficiency of one or more nutrients in the
population or specific population groups e.g. addition of iron to fortify cornflakes.
2. According to Harris six distinct philosophies of food fortification are:
1. Fortification for restorations to normal level.
2. Fortification above normal level.
3. Enrichment with public health objective.
4. Enrichment of ‘substitute’ foods to equivalent nutrient level.
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Public Nutrition
5. Fortification to make a food complete in itself.
6. Addition of nutrient for non-nutritional purposes.
3. The basic points one needs to keep in mind are:
a. There should be a demonstrated need for a nutrient in one or more
population groups.
b. Food selected as a vehicle for the nutrients must reach the population at
risk.
c. The amount of nutrient added to food, will supply adequate intake when
the food is consumed in normal amounts by population at risk.
d. The amount of nutrient added will not be toxic or harmful to individuals
with a high intake of the fortified foods.
e. The nutrient is biologically available in the form in which it is added and
is stable in the food selected as vehicle.
f. The food selected does not seriously interfere with the utilization of the
nutrient.
g. Addition of the nutrient has no detrimental effect on flavour, shelf life,
colour texture or cooking properties of the food.
h. Fortification is technically feasible for the particular food.
i. The cost of fortification does not result in a significant change in the cost
of food. A method of controlling and/or enforcing the level of fortification
available.
4. Nutrition communication convey information, persuade individuals to consume
food rich in micronutrients, choose fortified foods, and prepare food in new
ways to protect their nutrient content. Nutrition communication further can
help develop necessary skills and motivate people to make lifestyle changes.
1. Supplementation especially short-term is beneficial in combating malnutrition.
This is aptly justified as short term supplementation show compliance from
the community, foregoing or economic constraints and impact that is maximum
during a short-term strategy. e.g. Administration of folifer tables during the
course of pregnancy has seen a marked improvement in Haemoglobin levels.
However, long term use has seen lack of compliance, GI disturbances and
hence discontinuation of its use.
2. The limitations of adopting supplement as a strategy to combat malnutrition
are:
l It is an expensive strategy compared with other interventions
l It has a narrow scope of coverage in a population
l Long-term intervention is not effective and impactful leading to non-
compliance.
3. The points one would consider in selecting implementing an intervention
strategy are:
l Epidemiological considerations
l Level of country development
l Capacity of country to implement and sustain intervention
290 l Cultural considerations
Strategies to Combat
UNIT 13 STRATEGIES TO COMBAT PUBLIC Public Nutrition
Problems – II.
NUTRITION PROBLEMS - II
Structure
13.1 Introduction
13.2 Immunization
13.2.1 Importance of Immunization
13.2.2 Common Vaccine Preventable Diseases
13.2.3 National Immunization Schedule
13.3 Supplementary Feeding Programmes
13.3.1 Supplementary Feeding
13.3.2 Intervention Programmes to Combat Under Nutrition
13.4 Improving the Quality of Food Produced by Genetic Approaches
13.5 Clean Water, Sanitation, Street Foods and Strategies for Improvement
13.5.1 Importance of Clean water, Reasons for Water Contamination and its Harmful
Effects
13.5.2 Urban and Rural Sanitation and Strategies to Improve Sanitation
13.5.3 Street Foods and Strategies for Improvement
13.6 Improving Food and Nutrition Security
13.6.1 Sustainable Food Production to Meet Nutritional Needs
13.6.2 Community Food Banks
13.7 Let Us Sum up
13.8 Glossary
13.9 Answers to Check your Progress Exercises
13.1 INTRODUCTION
In Unit 12, we studied about some of the strategies such as food based approaches
(for example, dietary diversification, food fortification and horticultural interventions) to
combat malnutrition. We continue our study of strategies in this unit. The unit will focus
on five other different strategies, namely, immunization, supplementary feeding, genetic/
food biotechnology, improving water and sanitation services and food and nutrition
security to combat malnutrition. As your read through this unit, you will get the
perspective that a single strategy may not be sufficient to alleviate large problem of
malnutrition in our country. We may require more than one strategy, if we really want
to make an impact in alleviating malnutrition.
Objectives
l enumerate the various immunizations that are available in our country to prevent
the spread of major diseases,
l describe India’s major supplementary feeding programmes and some of the
successful programme strategies that have worked,
l explain the latest available facts regarding genetic foods and how to distinguish
between benefits and non-benefits of genetic foods,
l describe the importance of clean water and improved sanitation as an important
strategy to combat malnutrition, and
l elaborate on the efforts made by India to improve food production and the challenges
that remain.
291
Public Nutrition
13.2 IMMUNIZATION
Immunization, you might already know, is a process that increases an organism’s
reaction to antigen and therefore improves its ability to resist or overcome infection.
Antigen can be any substance ( as a toxin or enzyme) that stimulate the production
of antibodies. In this section, we will focus on the different aspects specific to
immunization i.e. what is the importance of immunization? What are the common
vaccine preventable diseases? What is the National Immunization schedule? Let
us start our study of immunization by first understanding why immunization is
important.
13.2.1 Importance of Immunization

You have learnt in Unit 3 that infection contributes to malnutrition in children by
affecting growth. Therefore, it becomes very important to prevent infection in children
so that they grow well. Immunization is one of the most cost-effective methods of
preventing infections and a critical strategy to combat public nutrition problems.
Immunization protects against several dangerous diseases by increasing body’s ability
to fight these diseases. Thus immunization prevents:
— life long physical and mental disabilities, and
— death from dreaded diseases
What are these dangerous diseases which can be prevented through immunization?
Let us find out.
13.2.2 Common Vaccine Preventable Diseases

The diseases which are prevented by immunization are known as Vaccine Preventable
Diseases. Most common diseases which are prevented by immunization are: Tetanus,
Poliomyelitis, Diptheria, Pertussis, Measles and Child Tuberculosis. Let us learn about
these diseases. We will start with Tetanus first.
l Tetanus: Tetanus is caused by a toxin produced by the bacillus – Clostridium
tetani. The organism is generally found in animal faeces. The disease is common
in the age group of 5-40 years as this age group is predisposed to all kinds of
injuries and the risk of acquiring tetanus is higher. In India and other tropical
countries, tetanus of the new born infant is very common due to bad hygienic
practices followed during delivery particularly for cutting the umbilical cord by
the untrained traditional midwives (dais). Women in the reproductive age group
of 15-45 years, females are at a higher risk, particularly after abortions and
deliveries conducted under primitive conditions in the rural and tribal areas.
Let us learn about poliomyelitis next.
l Poliomyelitis: Poliomyelitis is an acute communicable disease caused by a virus
It is principally an infection of the alimentary tract but affects the central nervous
system often leading to paralysis. It is essentially a disease of infancy and
childhood. The most vulnerable age is between 6 months and 3 years.
Let us go over to Diptheria now.
l Diptheria: Diptheria is an infection of the throat, nose or larynx and is caused
by the bacteria, corynebacterium diptheriae. It is most common in infants and
children but adults can also be infected with the disease. In the most common
form of disease, a thin membrane is formed in the throat. The infection can cause
complications in heart and nervous system.
292 Let us now discuss Pertussis.

l Pertussis: Pertussis or Whooping cough is caused by the microorganism Strategies to Combat
Bordetella pertussis or the pertussia bacillus. Whooping cough is an acute Public Nutrition
Problems – II.
highly communicable infection of the respiratory tract. It is primarily a disease of
infants and children. The disease takes a serious form in malnourished children
and may lead to death.
Let us move on to measles.
l Measles: Measles is an acute communicable viral disease, and is the most
serious of the common childhood diseases. Usually it causes a rash, high fever,
cough, runny nose and watery eyes lasting 1 to 2 weeks. It is responsible for
many child deaths because of complications from pneumonia, diarrhoea and
malnutrition.
Lastly let us get to know about Tuberculosis.
l Tuberculosis: Tuberculosis is a chronic disease caused by Mycobacterium
tuberculosis. It causes cough, fever and weight loss. It is transmitted by droplets
from sputum of infected persons particularly during coughing. Although it can
occur at any age, it is more prevalent among males over 45 years of age belonging
to low income group. It is an important cause of disability and death in many parts
of the world.
From the description about the common diseases you can see that these can be very
fatal. Therefore, vaccines against these dreaded diseases are given to all the infants.
Tetanus vaccine is given to pregnant women. Let us then get to know the immunization
schedule being adopted in our country.
13.2.3 National Immunization Schedule

You must have heard about your friends and relatives taking their children to the
doctors or health centers for immunization. There is a certain schedule of immunization
which they have to follow. So what do we mean by an immunization schedule? The
schedule that tells us when and how many doses of each vaccine should be given
is called an immunization schedule. It is important for us to know that the vaccines
must be given to individuals (infants, children and women) at the right age and in the
right dose. Full course must be completed to give the best possible protection to the
beneficiaries.
You would realize that each country follows its own immunization schedule depending
upon the disease/disorders prevalent in that country. In India, we follow an Immunization
schedule, as given in Table 13.1, under which two doses of tetanus toxoid (TT) are
given to pregnant women, three doses each of oral polio vaccine (OPV) and a triple
injection Penta valent and one dose each of BCG and measles are given to infants.
Look up Table 13.1 carefully and check the age, vaccine and route of dose provided.
In Table 13.1, you would also notice few booster doses included at specific ages. What
is a booster dose? A booster dose is an additional dose that makes sure that the first
dose was effective. Booster doses of vaccines are given to children to ensure full
protection. First booster doses of OPV and DPT is given around the age of 16-24
months and a second booster dose of DPT is given around 5-6 years of age. In
addition, two TT doses are given at the ages of 10 and 16 years
Besides the vaccines for infectious diseases, oral prophylactic dose to prevent
certain nutrient deficiency disorders is also given. For example, oral prophylactic
dose of vitamin A is given at 9 months along with measles vaccine. Thereafter,
6 monthly dose of vitamin A is given to children till 3 years of age. You may recall
reading about administration of Vitamin A doses under “National Prophylaxis
Programme for Prevention of Blindness due to Vitamin A deficiency” in Unit 10 of
this course.
293
Public Nutrition Table 13.1: National Immunization Schedule (NIS) for Infants, Children and
Pregnant Women
Vaccine When to give

For Pregnant Women
TT-1 Early in pregnancy
TT-2 4 weeks after TT-1
TT- Booster If received 2 TT doses in a pregnancy within the
last 3 yrs
For Infants
BCG At birth or as early as possible till one year of age
Hepatitis B-Birth dose At birth or as early as possible with in 24 hours

OPV-0 As birth or as early as possible
within the first 15 days
OPV 1, 2 & 3 At 6 weeks, 10 weeks & 14 weeks
(OPV can be given till 5 years of age)
Pentavalent 1, 2 & 3 At 6 weeks, 10 weeks & 14 weeksv
(OPV can be given till 5 years of age)
Rotavirus At 6 weeks, 10 weeks & 14 weeks
(can be given till one years of age)
IPV Two fractional dose at 6 and 14 weeks of age
Measles/MR 1st Dose 9 completed months-12 months.
(can be given till 5 years of age)
JE-1 9 completed months-12 months
Vitamin A (1 dose) At 9 completed months with measles-Rubella
For Children
DPT booster-1 16-24 months
Measles/MR 2nd 16-24 months
Dose
OPV Booster 16-24 months
JE-2 16-24 months
Vitamin A 16-18 months. Then one-dose every
(2nd to 9th dose) 6 months up to the age of 5 years.
DPT Booster-2 5-6 years
TT 10 years & 16 years
TT: Tetanus Toxoid; BCG: Bacillus Calmette-Guerin; OPV: Oral Polio Vaccine; IPV: Inactivated
Polio Vaccine; JE: Japanese Encephalitis; DPT: Diptheria, Pertusis, Tetanus
Source: Accessed from the website mohfw.gov.in on 1.04.2019.
Another aspect, we need to highlight is that immunization is absolutely essential. Minor
illnesses, including mild fever, coughs and colds, as well as, malnutrition, are not a
contra-indication to immunization. Immunization should be postponed only if children
are seriously ill or have high fever as any aggravation in the condition of the child may
be attributed to immunization. The children should, however, be immunized as soon as
they recover. The longer the immunization is delayed, remember the longer the child
294 is exposed to the risk of infection.
In this section you learnt about, immunization as a strategy to combat malnutrition. If Strategies to Combat
Public Nutrition
the children are protected from diseases by immunization, they would be healthier and
Problems – II.
less likely to become malnourished. In the next section, we would learn about the
second strategy to combat malnutrition, that is, supplementary nutrition. Now, before
we move on to this section let us recall what you have learnt so far.
1. Explain the term “immunization’ and its relevance as a strategy to combat
malnutrition.
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
2. Name the six common vaccine preventable diseases.
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
In India, we follow an Immunization schedule, under which:
a. Pregnant women receive two doses of ................................. toxoid.
b. BCG is given to infants at ..................................
c. Infants receive triple injection of .......................along with oral ...................
dose at 1-1/2 months, 2-1/2 months and 3-1/2 months respectively.
d. Measles vaccine is given to infants at the age of .......................... months.
e. A booster dose of DPT and polio is given to children at .............
.................... months to give added protection from diseases.
Let us now move on to the next strategy i.e. Supplementary feeding to combat public
nutrition problems.
13.3 SUPPLEMENTARY FEEDING PROGRAMMES

Supplementary feeding in literary terms means extra food or the food which makes up
for a deficiency in the normally consumed diets of individuals. In this section, we will
learn about what supplementary feeding means as a strategy to combat malnutrition
and why it is required? In Unit 10, you have already learnt about various nutrition
intervention programmes implemented by the government. Here we will briefly review
the supplementary feeding component of these national programmes. Before we discuss
this, let us first understand what is meant by supplementary feeding.
13.3.1 Supplementary Feeding
Supplementary feeding, is the food provided to pregnant, lactating women, children and
adolescents to fill the gap between the average calorie intake and national recommended
dietary allowances. It addresses the problem of food and nutrition security in the
vulnerable population and provides extra calories and nutrients for growth and
development at the critical stages of life cycle. You should remember that supplementary
feeding aims only at supplementing and not substituting the family food. Let us look
closely as to why, at all, we need to provide supplementary feeding to vulnerable
population.
You have learnt in Unit 9 that National Nutritional Monitoring Bureau conduct dietary
surveys in the country on a regular basis. Surveys from National Nutritional Monitoring
Bureau (2012) show that about 54-70% of households in India consume less than 50%
of protective foods such as GLV`S, milk & milk products, sugar & jaggery as per the 295
Public Nutrition RDA’s. Diets of children under the age of 5 years are far more inadequate than those
of adults and are well below the recommended dietary allowances. Dietary surveys
also show that diets lack in micronutrients such as iron and vitamin A. About 80% of
the individuals consume diets which provide less than half of recommended dietary
allowances. Problems of inadequate dietary intake are more pronounced in the low
income households.
So, what is the outcome of poor diet and benefits of food supplementation, especially
in vulnerable population like pregnant women? Various research studies in developing
countries have shown that in pregnant women, a reduction in dietary intake below the
habitual levels and increased workload above the habitual levels are associated with
deterioration in maternal nutritional status and reduction in birth weight of infants.
Research has also shown that in such cases if the pregnant women are given adequate
continuous food supplementation and antenatal care, there is substantial improvement
in outcome of pregnancy including birth weight and neonatal mortality. Similarly for
children (1-6 year), “catch up growth” is possible with food supplementation. The term
“catch up growth”, of course, means that the child catches up on the growth that could
not be achieved earlier. If we provide the 1-6 year aged children with right inputs, that
is extra food, clean water and hygienic conditions, it is possible for these children to
make up for the earlier deficits in growth and development.
It is for these reasons that government of India has included food supplementation as
an integral component in some of its major programmes, so that pregnant women,
lactating women and young children can be benefited from food supplementation. You
have already learnt about these programmes in Unit 10. In this unit, you will learn about
supplementary feeding component of these programmes. Let us now consolidate our
knowledge and recapitulate the supplementary feeding component of various intervention
programmes.
13.3.2 Intervention Programmes to Combat Under Nutrition
We already know that there are many programmes in the country run by non-government
and government organizations which have supplementary nutrition as an integral part
of their intervention activities to combat malnutrition. In this section, we would discuss
such programmes. We would learn about three major government programmes and
four large Research Action Programmes (RAPs). Research Action programmes are
those, whose strategies have worked for the ICDS and have been integrated into state
level or regional level ICDS programme. Of the three government programmes, two
are implemented through anganwadi centers (a grassroot infrastructure based in the
community) and the other one is implemented in the schools. These are listed in the
Table 13.2 as follows.
Table 13.2: Supplementary Food Programmes
Implemented Through Implemented Research Action Programmes
Anganwadi Centers Through Schools
1) Integrated Child National Mid Day 1) POSHAN (CMAM) (2015-2018)
Development Services Meals Programme 2) The Integrated Nutrition And
(ICDS) Health Project (INHP) in Eight
States of India (1996-2006)
2) Pradhan Mantri 3) The Bal-Poshan Project,
Gramodhya Yojana Rajasthan (1993-2003)
(PMGY) 4) The Regular Incorporation of
ARF in The Ready-To-Eat
Complementary Food for the
‘Under 3s’ in the ICDS of
Karnataka, Tamil Nadu,
Andhra, Kerala, and the
Union-Territory of Pondicherry
296
(1992-Continuing)
Let us study about the supplementary feeding components of each of these programmes. Strategies to Combat
Let us start with government programmes implemented through anganwadi centers. Public Nutrition
Problems – II.
We will start with ICDS.
A. Programmes implemented through anganwadi centers
Integrated Child Development Services
In Unit 11 we studied about objectives, target group and services provided by Integrated
Child Development Services (ICDS). In this section we will once again recapitulate
the supplementary feeding component of ICDS.
The supplementary feeding component of the ICDS, we learnt, aims at providing food
supplements to the vulnerable groups. The objective of providing supplementary food
is to supplement the home diet i.e. add extra food to the home diet of the individuals
so as to fill the gap in energy and protein and meet the RDI’s for these individuals.
The type of food supplements in the ICDS programme varies from state to state, from
ready-to-eat food to hot cooked meals at the anganwadi. The calorie and protein
content of ICDS food supplements is given in the Table 13.3.
Table 13.3: Calorie and protein content of food supplements provided at
Anganwadis
S.No. Recipients Calories (kcal) Protein (g)
1. Children 6 months to 72 months 500 12-15
2. Adolescents 600 18-20
3. Pregnant and lactating women 600 18-20
4. Severely Malnourished Children 800 20-25
(6 months - 72 months)
In Table 13.3, you would note that adolescent girls are also included as beneficiaries
for supplementary food but in practice supplementary food is provided to adolescents
in some states only. This is not a routine practice. In the ICDS programme, the
emphasis was initially on providing cooked food through on-the-spot feeding in the
anganwadi because it was believed that
l this would ensure that the targeted child would get food supplements, which
would not be shared between other members of the family; and
l the anganwadi centres would provide practical nutrition education to women on
cooking and feeding young children.
However, on-the-spot cooked food feeding programme are found to have several
disadvantages as well. These are:-
l children especially those in the age group of 6-36 months could not consume the
entire amount of food provided because of a small stomach capacity;
l even if older children do eat the food provided in the anganwadis, this acts mainly
as a substitute, and not an addition, to home food;
l the most needy segments viz., children in the critical 6-36 month age group and
women, were not able to come to the anganwadis daily and receive the food;
l providing food supplements only to the children from Below the Poverty Line
(BPL) families or those with under-nutrition was not possible as it was difficult
to feed one child and withhold food from another in the same anganwadi;
l cooking food, feeding the children and cleaning the vessels at the anganwadi took
up most of the time of the anganwadi workers and helpers, leaving them little time
for other important activities such as growth monitoring, nutrition education, or
pre-school education; 297
Public Nutrition l in any mass cooking and feeding programme, the monotony of the food provided
and relatively poor quality of the preparations was a problem;
l cooking in poor hygienic conditions and keeping left-over food resulted in bacterial
contamination of food;
l under-nourished children, even those in the 3-6 year age group, if given double
rations, did not consume all the food at one sitting in the anganwadi.
So as for today, the supplementary food in most cases is, ready to eat, which is
distributed at the anganwadi centers.
Next let us move on to the next programme i.e. Pradhan Mantri Gramodhaya Yojana.
l Pradhan Mantri Gramodhaya Yojana
Pradhan Mantri Gramodhaya Yojana (PMGY), aims to achieve the sustainable human
development at the village level. It provides for basic minimum services of rural roads,
primary health, primary education, shelter and drinking water and nutrition in order to
focus on these priority areas. The nutrition component of PMGY specifically provides
food supplementation to children 6 months-3 years of age through take home ration
(THR) as this age group is not able to attend anganwadi centers on a daily basis. The
guidelines for provision of calorie and protein content of food supplement are same
as those for ICDS, since it supplements the ICDS scheme. The nutrient contribution
of the supplement is given in Table 13.3. There is a shift in focus from providing
cooked food at anganwadis to take-home food supplementation under the PMGY.
Undoubtedly, the take-home food supplements provided will be shared with the family,
but that would add to household food security. When coupled with nutrition education,
the under-nourished persons may get their due share.
Let us now learn about the research action programmes whose strategies have worked
for ICDS.
B. Research Action programmes
There are many research action programmes which had been/or are being implemented
in different states of our country to improve the nutritional status of vulnerable groups
in convergence with ICDS. Brief review of some of such programmes are discussed
herewith.
l POSHAN (CMAM) Project in Rajasthan
Positive and Optimum care of children through a Social and Household Approach for
Nutrition (POSHAN) at Rajasthan is a unique and innovative approach to Community-
based Management of Acute Malnutrition (CMAM).
Under this approach, children in the age group of 6 to 59 months are treated at their
respective homes and family settings, where the children are most comfortable. As an
advantage of this, POSHAN (CMAM) is able to reach to more children than the traditional
facility-based care approach.
POSHAN Phase-I (2015-2016) was piloted in 13 priority districts (10 High Priority Districts
(HPDs) and 3 Tribal Districts) of Rajasthan with support from development agencies
ACF/ AAH, GAIN and UNICEF. A total 2,34,404 children aged between 6 months and
59 months were screened in 41 blocks in 1,574 villages and 9,640 Severely Acute
Malnutrition (SAM) children were identified. Out of which 9,117 children recovered
from SAM between 8 and 12 weeks of sustained intervention. The programme was
concluded in June 2016, with a recovery rate of 88%.
After the successful implementation of the POSHAN Phase-I programme, phase-II of
the programme was initiated, which was named as POSHAN Baran project. In this
298
phase 63 villages of two blocks of Baran – Kishanganj and Shahabad, between July Strategies to Combat
Public Nutrition
2017 to March 2018, covered 6,304 children of the same age group. Problems – II.
While screening, 341 children were identified as SAM, who were treated through the
CMAM in which the children were given free POSHAN Amrit i.e., a micronutrient
enriched, energy dense nutrition supplement as a take-home ration. Apart from this, 402
other children were identified as MAM (Moderately Acute Malnutrition) and were referred
to Aanganwadi centers for their treatment.
The regular home visits were utilized to regularly monitor the child's health and counsel
caregivers regarding hygiene practices, aspects of managing and treating malnutrition.
This helped to ensure compliance with the treatment and provide support to caregivers
eventually building their capacities in childcare to follow to achieve optimum care of
children. The children discharged from the programme were followed for 4 months to
ensure they do not fall back to the same state of malnutrition.
Let us now move on to another research action programme i.e. The Integrated
Nutrition and Health Project .
l The Integrated Nutrition and Health Project (INHP) in Eight States of

India (1996-2006)
The Integrated Nutrition and Health Project (INHP) was a ten-year project (1996-
2006- with two phases of 5 year each) implemented by CARE with the goal of
achieving “sustainable improvement in the nutrition and health status of women and
children. The project was implemented in partnership with the Women and Child
Development and the Health and Family Welfare Departments of Government of
India, Non-Governmental Organizations and Community Based Organizations with
support of United States Agency for International Development (USAID). The INHP
worked with families having pregnant women, lactating women and children under 2
years of age (Under 2s) in eight Indian states reaching approximately 100,000
Anganwadi Centers (AWC). The programme was so designed as to strengthen and
complement the ICDS programme.
The review of the first phase of the project highlighted two unique features of the
INHP. These were Take Home rations and Convergence of Health and Nutrition
Services at the Anganwadi center. Let us look at these in detail:
“Take-Home-Rations” or THRs: The review highlighted that the THR strategy for
children, the pregnant and lactating mothers had several advantages. It showed that
THR strategy
l had very high geographical reach
l covered the majority of “under 2s”
l was convenient for the mothers
l was less expensive than ‘fed-on-site’
l minimized cross infections
l treated undernutrition in its milieu
l provided more emotional security to the child as child was fed in her/his home
l was the most practical ‘child-care-education’ for the mother, and
l most importantly ensured weight gain inspite of ‘sharing’ of the THR.
Let us look at the other feature. 299

Public Nutrition Convergence of Health and Nutrition Services at the Anganwadi
It provided for convergence of Health and Nutrition Services at the Anganwadi on a
pre-specified date and time. The Nutrition and Health days were usually held twice a
month or once a week. The supervisor, Anganwadi Worker (AWW), the helper, Auxiliary
Nurse Midwife (ANM), the community change agent were present on Nutrition and
Health days. On these days, THR rations were distributed, the ‘under 2s’ are weighed,
and Nutrition and Health education was given. The mothers willingly helped and
participated.
“The INHP version of the ICDS” had reached programme scale in 2003.
Let us now move on to the third research action programme.
l The Bal-Poshan Project, Rajasthan (1993-2003)
The Bal-Poshan Project was an improved ICDS model implemented in five districts
of Rajasthan from 1993 to 2003. The project involved the participation of Self Help
Groups (SHGs) who made the Amylase-Rich-Food (ARF) from wheat grains and sold
it to ICDS who distributed the ‘ARF-Packets’ in their weekly THR.
Now what is Amylase Rich Food? Well, Amylase Rich Food is germinated cereal flour
which is rich in an enzyme “Amylase”. ARF reduces the viscosity of cereal based
gruel by breaking down the starches present in it. Thus, if added to a cereal based
food for an infant, ARF will make the food thinner so that the infant can consume it
easily. The unique features of Bal-Poshan project were:
l The responsibility for caring for the children under 3 years of age was transferred
to the parents. In the weekly THR, paediatric iron-folate-tablets, deworming tablets
(if required), the weekly ration of staple grains and oil were also given.
l Simple Information - Education-Communication was incorporated in the project
regarding the use of the various components of the THR namely, ARF, iron folate
tablets, grains/oil etc.,
l The Anganwadi center was ensured to have adequate stocks of common medicines
such as ORS, anti-malarials, and deworming tablets.
You can see for the first time how SHGs were involved in preparing nutritious supplement
for under 3 children in the ICDS programme. So in the true sense, Bal-Poshan project
contributed to providing supplemental food to ICDS.
Let us look at the fourth research action programme.
l The Regular Incorporation of ARF in The Ready-To-Eat Complementary
Food for the ‘Under 3s’ in the ICDS of Karnataka, Tamil Nadu, Andhra,
Kerala, and the Union-Territory of Pondicherry (1992-Continuing)
The Regular Incorporation Of ARF in the Ready-To-Eat Complementary Food for
children under 3 years of age (U3s) in the ICDS of Karnataka, Tamil Nadu, Andhra,
Kerala, and The Union-Territory of Pondicherry began in 1992. This research action
programme as the name suggests involves adding ARF to ready to eat complementary
food for children under 3 years of age. The underlying principle of this programme is
that ‘U3s’ need both their macro as well their micronutrients day-in and day-out. An
infant of one year of age requires half of what his father eats, or about 1,200 Kcal /
day. He/she needs nutrient dense yet low bulk foods that will satisfy his macro hunger
for calories and protein; and his micro-hunger for vitamins and minerals. Hence, a THR
of grains will not do for this special category. She / he need a RTE-THR. This helpless
and hapless child is in a chronic state of hunger. Further an infant born of an
undernourished mother, suffers even more from iron, zinc, vitamin A, B-complex and
vitamin-C deficiencies. The miracle of ARF is that it literally ‘liquefies’ as an almost
300
solid to semi-solid-gruel which the ‘U3s’ usually get. Strategies to Combat
Public Nutrition
The various factories making the RTE food for the ‘U3s’, routinely add 5 to 7% ragi Problems – II.
malt to the RTE – processed and precooked complementary food-powder. Actually,
barley malt is the most powerful ARF, where only 1 to 2% of the malt needs to be
added to the RTE – complementary food. However, since the procedure for sprouting
ragi is well-known in South India, the Karnataka Agro Corporation (Ltd.) (one of
the companies making RTE) sub-contracts self help groups (SHGs) to sell them the
ragi-ARF. However, it is important to know that while preparing RTE -complementary
food, the use of safe-water is essential in the sprouting process. This has been one
of the problems of SHGs, namely, lack of hygiene, and lack of safe water. It is,
therefore, essential that the entrepreneurs or SHGs set up safe and hygienic units and
evaluate the same from time to time with Hazard Analysis Critical Control Point
(HACCP).
There are some recommendations which flow from the experience of implementation
of this programme. These are:
l Social production, social marketing and social advertising should be our war cry
and slogan for promotion of complementary foods.
l The need of the hour is the manufacture of sachets (like a shampoo sachet) for
say, Rs. 2/- sachet. This sachet or sprinkler (as it is called in the USA) would
contain daily Recommended daily Requirements (RDA) of vitamins / minerals for
the ‘U3s’ + just 2g of a hygienically produced barley malt. Such a sachet /
sprinkler (packed in aluminium laminate) has a shelf-life of upto 3 years.
Let us now review the national programme implemented in the school.
C. National Programme Implemented in Schools
The Mid day Meal Scheme is a school meal programme of Government of India
designed to better nutritional standing of school age children, about which we studied
in Unit 10. Here we will briefly review the supplementary feeding component of the
programme.
National Mid-Day Meals Programme (NMDM)
We learnt that the supplementary feeding component of the programme consists of :
l 100 g food-grains (wheat or rice) for primary and 150 g for upper primary child
per school day, where cooked meals are served;
l 3 Kgs. food grains per student per month, where food grains are distributed.
As of now, all states and UTs are providing cooked meals to all primary school
children. All the states are distributing food grains under the programme too. However,
in the interim, until the institutional arrangements are made for providing cooked meals,
states are providing food grains.
Since it is such a big programme, it will be good to learn about the systems set up in
the country to monitor the food component of the programme. GOI has developed a
computerized Management Information System with the assistance of the National
Information Centre, New Delhi. The system provides for recording data on enrolment,
eligible beneficiaries for NMDM, quantity of food grains allocated, lifted and utilized
in each block. However, no State or UT has been able to sufficiently master the
computerized format as yet.
Thus, we saw how different programmes in the country provide supplementary nutrition
to children, pregnant and lactating women. Of course, there is a lot to learn from these
and there is also a scope for improving these programmes.
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Public Nutrition
1. Explain the term “Supplementary feeding” and its relevance as a strategy to
combat malnutrition.
...........................................................................................................................
...........................................................................................................................
2. Enumerate the target group, calories and protein provided by ICDS food
supplement.
.......................................................................................................................
.......................................................................................................................
3. What are the research action programmes whose strategies have worked for
ICDS?
.......................................................................................................................
.......................................................................................................................
a. Bal Poshak project in Rajasthan was a unique project, in which self help
groups were involved in preparation of food supplements for young children.
b. One of the disadvantages of on the spot cooked food feeding programme
in ICDS is the poor out reach of 6-36 months old children.
c. NMDM has helped to boost enrollment in primary schools.
d. PMGY specifically provides food supplementation to children 3-6 years of
age.
e. Project Poshan CMAM was pilot tested in Rajasthan.
In the above section, we learnt about supplementary feeding and how various
supplementary feeding programmes form an important strategy to combat malnutrition.
Let us now move on to the next strategy to combat public nutrition problems. This
strategy focuses on how we can improve the quality of food or nutritional value
through genetic or food biotechnology.
13.4 IMPROVING THE QUALITY OF FOOD

PRODUCED BY GENETIC APPROACHES
Genetic or food-biotechnology is a plant breeding science. It means the transfer or the
implantation of a gene(s) that is abundant in another plant or living organism species
to the one that is to be enriched. Genetic or food biotechnology can help us to improve
the nutritional situation of people in two ways. First, this approach can help us to
improve the nutritional quality of staple foods. Secondly, it can help us to produce crops
which have greater resistance to external harmful agents (e.g. pests etc.).
Certain staple foods like wheat, rice and potato can be enriched with -carotene, iron,
zinc and the amino acid - lysine using genetic/food biotechnology Genetic
approaches have been successful in producing -carotene-rich wheat; -carotene-
rich maize; -carotene-rich potato; -carotene-rich-sweet-potato; -carotene-rich-
cassava. Action-research is required to assess producer (farmer), manufacturer, and
consumer acceptance.
Food biotechnology can help in enriching the vitamin, mineral and amino acid content
of certain staple foods. Let us look at the second aspect of food biotechnology in
improving nutritional situation, that is, how it can be used to show improved resistance
302 to external harmful agents.
Genetically modified foods have been shown to exhibit improved resistance to several Strategies to Combat
harmful agents such as virus, insects and herbicides. They have also shown Public Nutrition
Problems – II.
improvement in the shelf-life. There are many advantages which have been demonstrated
in genetically or biotechnologically modified crops. The Malaysian Agricultural Research
and Development Institute, Malaysia has done excellent work with respect to rice,
papaya and oil palm. Some of these advantages are:
l Rice strains are more resistant to the tungro spherical form virus.
l Rice strains are more resistant to the bacilli form virus.
l Rice strains are more tolerant to herbicides.
l Rice strains are more resistant to insects
l Papaya strains are more resistant to ring-spot-virus.
l Papaya strains have an improved shelf-life.
l Oil palm strains have oil quality improvement.
l Oil palm strains have resistance to herbicides.
l Oil palm strains have resistance to insects
l Oil palm strains have resistance to fungus.
Thus, we studied that genetic modification of food can go a long way in combating the
problem of malnutrition in India. However, policy makers, implementers, producers and
consumers should be educated about the merits and demerits of genetically modified
foods.
In the above section, we learnt about how genetic/food biotechnological approaches
can help to improve the quality of food and offer great opportunity to reduce malnutrition
in India. In the next section, we will learn how improving water and sanitation is an
important strategy to alleviate malnutrition. Let us move on to this strategy:
13.5 CLEAN WATER, SANITATION, STREET

FOODS AND STRATEGIES FOR
IMPROVEMENT
Access to clean water and sanitation is a very important strategy to combat malnutrition.
If the clean water and proper sanitation are not available to families and communities,
the individuals can suffer from water borne infections. Infections, as you know cause
malnutrition. You have already read about vicious cycle of malnutrition and infection in
Unit 3 under causes of malnutrition. Thus, it is important to provide clean water and
proper sanitation to people, so that people are prevented from these infections and stay
in good health.
This section is divided into three parts. In the first part, we will learn about the
importance of clean water, how water gets contaminated and the harmful effects of
contaminated water. We will also learn as to how we can improve the quantity and
quality of water supply in our country.
In the second part, we will learn about sanitation and some strategies to improve urban
sanitation in India. We will also review some success stories, which have helped to
improve sanitary services in India.
In the third part, we will learn about street foods and some initiatives taken by the
government, which demonstrate how street foods can be made more hygienic and
safe.
Let us begin by understanding the importance of water, how the water gets contaminated
303
and the harmful effects of contaminated water.
Public Nutrition 13.5.1 Importance of Water, Reasons for Water Contamination and
its Harmful Effects
Water is essential for life. In fact, one can survive without food for weeks but not
without water. Water is a macronutrient made up of two elements, namely hydrogen
and oxygen. Vegetables contain 70% to over 90% water; so do fruits. Even cereals
contain over 10% water. If the food we eat is grown on contaminated soil (chemical
effluents, or containing large amounts of human excreta), then, the roots of the food-
plants or crops will suck up this contaminated water and in turn infest or infect the
human beings who consume these plant-foods. This is becoming a perennial problem
in our 21st Century. As for the water we drink, the source of water in most urban
areas is neither clean nor safe. Very often the mains (large tubes conveying water
from the source) and tubes, are contaminated with sewerage mains. Water contaminated
with faecal matter forms the single most important factor in the spread of gastro-
intestinal diseases (diarrhoea, dysentery or even cholera). Tube-wells are a common
sight these days. They also are the culprit for the spread of gastrointestinal disease.
Here again sewerage can easily enter shallow tube wells.
Let us now move on to how we can improve the quantity and quality of water supply
in our country.
Quantity of Water: It has been predicted that by mid-century (2050) water will
become so scarce that wars will be waged for water. India is fortunate in that it has
a perennial source of water from the Himalayas. We also have an extensive coast-
line where future technology can also transform or convert sea water to drinking or
potable water as in Israel. However, what is little realized is that the quantity required
for drinking / cooking / washing purposes is just about 10 to 15% of the total quantity
of available water. Most of the water is used in irrigation. Here again, genetic or
biotechnology, can create seed strains that require much less water. Drip irrigation is
another avenue to save water.
Quality of Water: India has constituted the Rajiv Gandhi Water Commission in 2000
to make improved quality of drinking water and sanitation services available to people.
In the urban setting, the Water boards (who oversee the distribution of water) could
do the following:
l Replace all water and sewerage mains.
l Oversee and regulate the depth that tube-wells should be bored. They should be
community, colonies and habitations-specific.
l Set-up water-purification plants at the source from where water will be drawn
and distributed.
l Continuously test water, samples at source (rivers tanks) and at end-delivery
points, namely, public-taps or tube-well-taps. Take immediate and necessary action.
l Levy a small fee for water-management to all i.e. slums, to the High Income
Groups (HIGs).
l Control the huge inflow of rural population pouring into urban areas. Set-up
‘migrant-shelters’ on the fringe of urban settlements. Provide safe water (quantity
and quality).
l Set-up washing areas in our ‘mandi’ markets and mandate that only clean and
washed vegetables and fruits will be sold.
l Encourage rain-water harvesting wherever possible, starting with Public Institutions,
eg. Government Offices.
l Provide micro-finance to the women in slums and Lower-Middle-Income (LIG)
housing colonies to manage their own water requirements.
304
l Monitor the water and sanitation position during the rainy season. Strategies to Combat
Public Nutrition
l Make village Panchayats responsible for ensuring enough water (quantity and Problems – II.
quality); the maintenance of taps and bore-wells; and for rain-water-harvesting.
l Encourage Food-for-Water-Management Schemes which can employ the youth

of the village.
l Water and sanitation go hand-in-hand, especially in Rural India where the concept
of sanitation barely exists.
l Mandate that rural-housing-loans will incorporate the basics of water and sanitation.
l Since times immemorial rural populations have been contaminating their water-
sources. Hence, institute an appropriate Information-Education-Communication
(IEC), starting with the Panchayat to the village school.
l Monitor water and sanitation position during the rainy season monsoons.
You can thus see that Government of India is taking several measures to to improve
the quality and quantity of water supply.
Let us now learn about sanitation and some strategies to improve urban sanitation in
India.
13.5.2 Urban and Rural Sanitation and Strategies to Improve

Sanitation
Sanitation has to be viewed as a package, namely, personal hygiene, family hygiene,
community and environmental cleanliness. Sanitation is deplorable for the migrant
population, the abjectly poor and the Low Income Group (LIG) in India. Unless the
communities who need it the most agitate for sanitary latrines and maintain it, the
situation cannot improve.
Let us review some strategies to improve urban sanitation:
l The slums should come forward and demand improved sanitation services.
l The Media should play an active role and influence the public and policy makers
to provide for improved sanitation services.
l Women, especially those who stay at home, are the most affected and should be
trained in the construction and maintenance of low-cost-latrines.
l As stated earlier, it is the migrant population who should be kept out of city limits,
but provided with minimum levels of water and sanitation.
l Research development and technology is urgently needed for specific low cost
latrines to suit different geo-hydrological conditions.
Now let us proceed to some success stories in India.
l To accelerate the efforts to achieve universal sanitation coverage and to put focus
on sanitation, the Prime Minister of India launched the ‘Swachh Bharat Mission’ on
2nd October, 2014. Sawchh Bharat Mission basically aims to clean up the roads,
streets and infrastructure of India’s cities, towns and rural areas by 2nd October,
2019. Under the campaign provisions for setting up of toilets both at households and
community levels are also provided.
l Another campaign initiated in 1999 by Government of India naming ‘Total Sanitation

Campaign or Nirmal Bharat Abhiyaan (NBA), also focused on the construction of
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Public Nutrition low cost toilets and solid & liquid waste management. The NBA also laid emphasis
on to motivate the family members of rural households to use toilets through
awareness creation and health education programmes.
l National Rural Drinking Water Programme (NRDWP): NRDWP is a Centrally
Sponsored Scheme aimed at providing every person in rural India with adequate
safe water for drinking, cooking and other domestic basic needs on a sustainable
basis. As per the data of 2017, 1.7 million rural habitations provided drinking water
under the National Rural Drinking Water Programme, out of which 1.3 million (77%)
habitations are fully covered (defined as having at least 40 litres per capita per day
(LPCD)), 19.3% habitations are partially covered (safe water is available but below
40 LPCD) and 3.73% are “water-quality affected habitations”–meaning those with
contaminated water
l The Sulabh-Sanitary Latrines are now a common features in all our big cities and
towns. The concept of ‘pay and use’ has come to stay.
l SEWA in Ahmedabad, advances micro-credit to women in the urban informal
sector (Cart pullers, street-food vendors, construction workers) for housing which
has to include a certain amount for water and sanitation.
l Ahmedabad Parivartan: Over 1000 slums (informal settlements) and nearly 1500
chawls (tenements) Ahmedabad, housing approximately 300,000 families had
little or no access to basic urban services. In response to this growing problem,
the Ahmedabad Municipal Corporation launched Parivarthan (Meaning
transformation) an ongoing program which brings affordable and sustainable basic
infrastructure services, including water and sanitation, to these slums and chawls
of Ahmedabad. The project brought together target communities, local NGOs, and
the private sector in a meaningful partnership.
l SWAJAL – Uttar Pradesh: This World Bank – assisted SWAJAL project has
improved the rural water supply and sanitation services of over 10 lakhs people
living in 1000 villages in the UP hills and Bundelkhand. The community willingly
pays for operational and maintenance costs.
Thus, we have several successful projects aimed at improving sanitation services in
India. These need to be taken to scale before we could see significant improvement
in sanitary conditions in India.
Let us learn now about street foods and some of the initiatives taken up by the
government to improve the quality of street foods.
13.5.3 Street Foods and Strategies for Improvement

What are street foods? Street foods are ready to eat foods and beverages, prepared and/
or sold by vendors and hawkers, especially in streets and similar public places. India has
a rich history of street food vending reflecting the traditional local culture. Their easy
availability couples with wide variety and delicacy of the offering, not to forget the
comparative low prices, have made street foods popular with the all sections of society,
including the elite and international tourists.
Street food vendors typically operate from semi-permanent premises and use portable
booths food carts or trucks to sell their items. Street food business are usually owned and
operated by individuals or families. Apart from providing livelihood opportunities for
countless number of people nationwide, these businesses also make a substantial
contribution to the local economy. The Ministry of Urban Poverty Alleviation, GOI, has
estimated that there are about 100 Lakh street vendors in the country. About 20% of
them, that is, 20 Lakh are expected to be street vendors.
However, on the negative side, street vending is often associated with poor environmental
conditions with vendors paying little attention to the safe handling of food, hygiene and
306 sanitation. The microbiological quality of the foods served is therefore poor. Vendors
also often use non-permitted food colours. Thus, street food in India is often perceived Strategies to Combat
as being unhygienic and a major public health risk. Public Nutrition
Problems – II.
In recent past, several initiatives have been taken by the Government to improve the
quality of street food in India. Some of the initiatives are described herewith:
1. Swachh Bharat Swachh Pakwan - This is the project of the Ministry of Tourism
which aimed at upgrading the skills and hygiene standards of street food vendors to
enable these people to serve excellent brand ambassadors of the variety that India
offers.
2. Surakshit Khadya Abhiyan - This abhiyan has been launched by The Ministry of
Consumer Affairs, Food & Public Distribution in partnership with industry body,
CII, The National Association of Street Vendors of India (NASVI) and Voluntary
organization in Interest of Consumer Education (VOICE) to promote awareness
about food safety with a special focus on street food vendors.
3. Food Safety and Standard Authority of India (FFSAI) has a project called Clean
Street Food to enhance the popularity of street food by transforming it into a global
brand itself. By building on the lessons of past initiatives in the food area, the project
would focus on to train street vendors in aspects of safe food and hygiene so that
they may improve the quality of their offerings and thereby be in a position to
attract more customers and increase their earnings. Apart from this, the project will
play a big role in the social and economic uplift of the street vendor community by
providing them with skill training under the Government’s flagship Pradhan Mantri
Kaushal Vikas Yojana (PMKVY). Besides help India’s food streets to emerge as
new tourist attraction by themselves as in many other parts of the world. In
summation the project ‘Clean Street Food’ intent to achieve the following objectives:
 Make a global brand out of Indian street foods
 Raise health & safety standards of street foods
 Reduce incidences of street food-borne diseases
 Help street vendors to improve quality of offerings, attract more clients &
earn more
 Enable street food operators to move up in life
 Transform lives of millions of people at bottom of pyramid.
4. Another initiative taken up by the FSSAI is ‘Clean Street Food Hub’. A clean
Street Food Hub may be defined as “a hub or cluster of 50 or more vendors/shops/
stalls selling popular street foods, 80 percent or more of which represent local and
regional cuisines and meets the basic hygiene and sanitary requirements”. It excludes
fine dinning.
To upgrade the existing food streets across the country and provide safe & hygienic
local eating experiences for domestic and international tourists alike FSSAI with
the support of state government bodies has framed benchmarks for hygiene and
sanitary conditions including food safety and hygiene requirements, personal hygiene,
location and facilities, street food hub, water supply and quality, pest control, leftover
and waste disposal. Large scale training capacity building of street food vendors
would also be an integral part of this initiative. Credibility may be provided by
recognizing such streets as ‘Clean Street Food Hub’ through plaque/certificate of
excellence. Some of the general requirement/guidelines for a Clean Street Food
Hub are given below:
 The street food vendors shall be registered under Food Safety and Standard
(Licensing and Registeration of Food Businesses) Regulation 2011.
 FSSAI Registration number and Food Safety Display Board (FSDB) should
be displayed on the cart/kiosk.
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Public Nutrition
A right example for such kind of a Clean Street Food Hub is situated in the state
Ahmedabad. The Food Safety and Standards Authority of India (FSSAI) declared
Kankaria Lake area in Ahmedabad as country’s first ‘Clean Street Food Hub’. The
15th - century Kankaria Lake, with around 66 street food vendors, serves popular street
food to approximately 12 million people each year.

1. What is meant by genetic or food biotechonology?
..........................................................................................................................
..........................................................................................................................
2. Answer the following briefly
a. Five different foods which have been successfully produced with enhanced
content of  carotene through genetic/food biotechnology.
..................................................................................................................
..................................................................................................................
b. Two important minerals that have been added to wheat and rice through
genetic/food biotechnology.
..................................................................................................................
..................................................................................................................
3. What are the harmful effects of consuming contaminated water?
..........................................................................................................................
..........................................................................................................................
a. Four main activities, which the Water boards could take up to improve,
water quality in the country
..................................................................................................................
..................................................................................................................
b. Three important strategies to improve urban sanitation
..................................................................................................................
..................................................................................................................
a. World Bank assisted SWAJAL project has improved the rural water supply
and sanitation services of over 10 lakhs people living in 1000 villages in the
UP hills and Bundelkhand.
b. Street foods can become the cause of food borne disease due to unhygienic
practices of the vendors and vending areas.
c. In India, we have an excellent system to regulate the hygiene condition of
the street foods.
d. Kankaria Lake are of Ahmedabad has been certified as first Clear Street
308 Food Hub.
In the above section, we learnt how improving drinking water and sanitation services Strategies to Combat
Public Nutrition
is critical to combat malnutrition. Let us now review the last (but not the least)
Problems – II.
strategy, namely improving food and nutrition security to combat public nutrition problems.
13.6 IMPROVING FOOD AND NUTRITION

SECURITY
You have studied in detail about food and nutrition security in Units 2, 5 and 10. You
have realized by now that improving food and nutrition security remains a very important
strategy to combat malnutrition. People should have food accessibility and availability
at all times, so that they have enough food in their homes to meet their energy
requirements. In addition they should also consume foods of adequate nutritional quality.
You also learnt in Unit 10 that for low income population, Public Distribution System
(PDS) and Targeted Public Distribution System (TPDS) are important strategy to
provide food at low prices. We also know that food and nutrition security is affected
by regular food supply in India. Thus we would learn how India has sustained its food
production, but still, there are current problems, paradigm shift, and challenges that
remain in this area. Although our government has made consistent efforts to improve
availability of food for poor since the beginning of the first National plan, we would
learn about specific efforts made by the government in the Tenth National plan to
ensure adequate availability of foodstuffs for the poor. You should remember that we
should not always be dependent on the government to improve food and nutrition
security. The community should also make efforts to improve the same. Thus, we will
learn about innovative local efforts by the community and how these can contribute to
achieving nutrition security for the poor population.
13.6.1 Sustainable Food Production to Meet Nutritional Needs

India has made great strides in improving food production in last 50 years and one of
the major achievements in the last 50 years has been the green revolution and self-
sufficiency in food production. Food grain production has increased four-fold.
The Green Revolution ensured that the increase in food production stayed ahead
of the increase in population. The country has moved from chronic shortages to an
era of surplus and export in most food items. The country is self sufficient in food
grain production and currently there is a buffer stock of over 60 million tonnes.
Along with the steps to achieve adequate production, initiatives were taken to
reach foodstuffs of the right quality and quantity to the right places and persons at
the right time and at an affordable cost. Over the years, there has been improve-
ment in access to food through the PDS, the food for work programme has
addressed the needs of the vulnerable out-of-work persons. The ICDS programme
aimed at providing food supplementation for preschool children, pregnant and lactating
women, nearly covers all blocks in the country. The Mid-day meal programme aimed
at improving dietary intake of primary school children and reduction in the school drop
out rates.
However, now there is a paradigm shift from household food security and freedom
from hunger to nutrition security. Although, the food grain production has continued to
increase steadily, there has been a decline in the production of pulses. Per capita
consumption of fruits and vegetables also remains low. These items are also not
available at affordable prices to poor. Poor people continue to have diets which are
of low nutritional quality. Box 1 gives the progress achieved, current problems paradigm
shift and challenges in the area of food production. Our challenge is, therefore, ensuring
that adequate quantities of pulses or other protein rich foods such as milk, eggs, or 309
Public Nutrition
meat, which are also in short supply, must become more widely accessible, requiring
increased production and improved distribution and consumption.
Box 1 Progress Achieved, Current Problems Paradigm Shift and

Challenges in the Area of Food Production
FOOD PRODUCTION
Progress Achieved:
l The country has achieved self-sufficiency in food grains to meet the needs of the
growing population;
l There are ample food grain stocks.
Current Problems:
l ‘Green Revolution Fatigue’ in some areas;
l Productivity remains low;
l Improved food grain availability has not resulted in eradication of hunger or
reduction in under-nutrition especially in vulnerable groups;
l Very little attention is being paid to achieve integrated farming systems that will
ensure sustainable evergreen revolution essential for appropriate dietary
diversification to achieve nutrition security.
Paradigm shift needed:
l From self-sufficient in food grains to meet energy needs to providing food items
needed for meeting all the nutritional needs;
l From production alone to reduction in post harvest losses and value addition
through appropriate processing;
l From food security at the state level to nutrition security at the individuals level.
Challenges:
l Continue to improve food grain production to meet the needs of the growing
population;
l Increase production of pulses and make them affordable to increase consumption;
l Improve the availability of vegetables at an affordable cost throughout the year
in urban and rural areas.
Opportunities:
l Achieve substantial improvement in nutrition security;
l Achieve decline in macro and micronutrient under-nutrition.
So, you learnt that although we have achieved good progress in achieving self sufficiency
in food grains, we are still faced with many challenges and opportunities to improve
food and nutrition security .
Let us learn about some innovative local efforts by the community and how they have
contributed to achieving nutrition security for the poor population. One of the examples
of innovative efforts is Community Food Banks. Let us learn about this next.
13.6.2 Community Food Banks
Innovative local efforts can go a long way in improving nutrition security especially
for the poorer segments of the population living in vulnerable areas. Formation of local
food grain banks under the supervision of the PRIs to help in achieving nutrition
310 security for all and insulating the economically and socially deprived sections of the
community from seasonal food insecurity has been suggested. M.S. Swaminathan Strategies to Combat
Research Foundation, Chennai has proposed a Community Food Security System, and Public Nutrition
Problems – II.
its diagrammatic representation is shown in the Box 2.
Box 2 Features of Community Food Bank

Community Food Bank
Main features of the proposed food bank are:
l One bank for every village or cluster of villages with population ranging from
2000 to 5000;
l Supervised by a society or council chosen by the gram sabha;
l Managed by a stakeholder council, with different operations assigned to different
self-help groups;
l To be implemented with honesty, political neutrality, fairness, absence of
discrimination based on religion, caste, class, gender and political belief;
Box 2 gives main features of a community food bank and shows how a community
food bank is managed, supervised and implemented by community. Food bank thus
becomes a source of food for government and other agencies with the distribution
operations managed by the self help groups.
Thus, in this unit we learnt about various strategies to combat malnutrition and how
they have been contributing to reduction of malnutrition in the country.
Check our Progress Exercise 4

1. What is meant by Public Distribution System (PDS) and Targeted Public
Distribution System (TPDS)?
....................................................................................................................
....................................................................................................................
a. Our country is self sufficient in food grain production and currently there
is a buffer stock of over 60 million tonnes.
b. Improved food grain availability has not resulted in eradication of hunger
or reduction in under-nutrition especially in vulnerable groups.
c. We need a paradigm shift to improve food security at the state level to
nutrition security at the individual level.
d. The production of pulses has been rising steadily in India.
e. Community food banks are innovative local efforts which can improve
nutrition security, especially for the poorer segments of the population living
in vulnerable areas.
3. What are the progress achieved, current problems, paradigm shift, challenges
and opportunities in food production?
.........................................................................................................................
.........................................................................................................................
13.7 LET US SUM UP

In this unit, we learnt about five different strategies to combat malnutrition. These
strategies are Immunization, Supplementary feeding, Genetic/ food biotechnology,
Improving water and sanitation services and Food and nutrition security. Immunization
is a very important strategy to protect the children from diseases. All children should 311
Public Nutrition be immunized against the most common six vaccine preventable diseases. In our
country, we have comprehensive national programmes which provide supplementary
foods to children in addition to other services. We also have research action
programmes which provide/have provided supplementary foods to children. We need
to learn from these research action programmes and integrate their best practices into
national programmes in order to improve upon them. Genetically modified crops offer
a great opportunity to reduce malnutrition in India. Nutritional quality of staple foods
can be improved through genetic/food biotechnology. Policy makers, implementers
and consumers need to be made aware of the demerits and merits of genetically
modified foods. Great efforts are required in India to improve the availability of
drinking water and sanitation services especially in urban population. There are some
successful projects that have demonstrated how these services can be improved.
These projects need to be replicated and taken to scale to make an impact on overall
situation in the country. Street food vending is spreading rapidly all over the world.
These can become the cause of food borne disease due to unhygienic practices of
the vendors and vending areas. Research projects in the country suggest some
recommendations which should be implemented in order to make the street foods
hygienic and safe. The country has achieved self-sufficiency in food grains to meet
the needs of the growing population and we have ample food grain stocks. But
improved food grain availability has not resulted in eradication of hunger or reduction
in under-nutrition especially in vulnerable groups. In order to improve food accessibility
to vulnerable population, subsidized food grains are provided to people below the
poverty line under TDPS. There is also a paradigm shift now to move from food
security to nutrition security.
13.8 GLOSSARY
Action research : systematic enquiry designed to yield practical results capable of
improving a specific aspect of practice and made public to enable
scrutiny and testing.
Antigen : a substance that can trigger an immune response, resulting in
production of an antibody as part of the body’s defense against
infection
Antibody : proteins produced by immune system of human and higher
animals in response to the presence of a specific antigen.
Herbicide : any chemical substance that is toxic to plants; usually used to kill
specific unwanted plants, especially weeds.
Viscosity : internal property of a fluid that offers resistance to flow.

EXERCISES
1. Immunization is a process that increases an organism’s reaction to antigen and

therefore improves its ability to resist or overcome infection. Infection contributes
to malnutrition in children by affecting growth. Therefore, it becomes very
important to prevent infection in children so that they grow well. Immunization
is one of the most cost-effective methods of preventing infections and a critical
strategy to combat public nutrition problems
2. The common vaccine preventable diseases are: Tetanus, Poliomyelitis, Diptheria,

Pertussis, tuberculosis and measles

312
a. tetanus Strategies to Combat
Public Nutrition
b. birth. Problems – II.
c. DPT, polio
d. 9
e. 16-24.
1. Supplementary feeding, is the food provided to pregnant, lactating women and

children and adolescents to fill the gap between the average calorie intake and
national recommended dietary allowances. It addresses the problem of food and
nutrition security in the vulnerable population and provides extra calories and
nutrients for growth and development at the critical stages of life cycle.
2. The target group, calories and protein supplied by ICDS supplementary food is
given in the table as follows.
Target group, calorie and protein content of ICDS food supplements
S.No. Recipients Calories (kcal) Protein (g)
1. Children 6 months to 72 months 500 12-15
2. Adolescents* 600 18-20
3. Pregnant and lactating women 600 18-20
4. Severely Malnourished children 800 20-25
* Supplementary feeding provided to adolescents in some states only
3. Four Research Action Programmes whose strategies have worked for ICDS are:
l POSHAN (CMAM)
l The Integrated Nutrition and Health Project (INHP) in Eight States of India
(1996-2006)
l The Bal-Poshan Project, Rajasthan (1993-2003)
l The Regular Incorporation of ARF in The Ready-To-Eat Complementary
Food for the ‘Under 3s’ in the ICDS of Karnataka, Tamil Nadu, Andhra,
Kerala, and the Union-Territory of Pondicherry (1992-Continuing)
4. a. True
b. True
c. True
d. False, PMGY specifically provides food supplementation to children 6 months
to 3 years of age
e. False, NSPE does not provide health package to school children. Although
it has been strongly recommended that it should provide a health package
in addition to supplementary foods to school children.
1. Genetic or food biotechnology is a plant breeding science. It means the transfer
(transgenic) or the implantation of a gene/s that is abundant in another plant or
living organism species to the one that is to be enriched.
313
Public Nutrition 2. a. Genetic approaches have been successful in producing -carotene-rich
wheat; -carotene-rich maize; -carotene-rich potato; -carotene-rich-
sweet-potato; -carotene-rich-cassava.
b. Two minerals which have been added to staple foods through genetic / food
biotechnology are: Iron and Zinc
3. Water contaminated with faecal matter forms the single most important factor in
the spread of gastro intestinal diseases (diarrhoea, dysentery or even cholera)
4. a. Four activities which the Water boards could take up to improve water
quality in the country are:
i. Set-up water-purification plants at the source from where water will be
drawn and distributed.
ii. Continuously test water, samples at source (rivers tanks) and at end-
delivery points, namely, public-taps or tube-well-taps. Take immediate
and necessary action.
iii. Make village panchayats responsible for ensuring enough water (quantity
and quality); the maintenance of taps and bore-wells; and for rain-
water-harvesting.
iv. Encourage Food-for-Water-Management Schemes which can employ
the youth of the village.
b. Three important strategies to improve urban sanitation are:
i. The Media should play an active role and influence the public and
policy makers to provide for improved sanitation services.
ii. Women should be trained in the construction and maintenance of low-
cost-latrines.
iii. Migrant population who should be kept out of city limits, but provided
with minimum levels of water and sanitation.
5. a. True
b. True
c. False, In India, we do not have a regular system to regulate the hygienic
condition of the street foods.
d. True
1. The Public Distribution System (PDS) & Targeted Public Distribution System
(TPDS) are food subsidy programmes implemented by Govt. to provide food
security to the poor people in India. PDS supports grain prices and assures
buffer stocks when supplies fell short. PDS provides cereals and other essential
items to card holders at subsidized rates. TPDS was introduced in 1997 by the
Govt. Under this system, subsidized food grains are provided only to people below
the poverty line.
2. a. True
b. True
c. True
d. False- The production of pulses has been falling steadily. We need to increase
production of pulses and make them affordable to increase consumption.
e. True
314
3. The progress achieved, current problems, paradigm shift, challenges and Strategies to Combat
opportunities in food production are presented as follows: Public Nutrition
Problems – II.
Progress Achieved: the country has achieved self-sufficiency in food grains to
meet the needs of the growing population; there are ample food grain stocks.
Current Problems: ‘Green Revolution Fatigue’ in some areas; Productivity remains
low; Improved food grain availability has not resulted in eradication of hunger or
reduction in under-nutrition especially in vulnerable groups; Very little attention
is being paid to achieve integrated farming systems that will ensure sustainable
evergreen revolution essential for appropriate dietary diversification to achieve
nutrition security.
Opportunities: Achieve substantial improvement in nutrition security; Achieve
decline in macro and micronutrient under-nutrition
315
Public Nutrition
UNIT 14 PROGRAMME MANAGEMENT
AND ADMINISTRATION
Structure
14.1 Introduction
14.2 Concept of Programme Management and Administration
14.3 Personnel Management
14.3.1 Role of a Personnel Manager
14.3.2 Skills Required by a Personnel Manager
14.3.3 Functions of a Personnel Manager
14.4 Planning, Implementing and Evaluating Public Nutrition Programmes

14.5 Techniques for Conducting Situational Analysis Needs Assessment
14.5.1 Key Informant Approach
14.5.2 The Public Forum Approach
14.5.3 The Nominal Group Process
14.5.4 The Delphi Technique
14.5.5 The Survey Approach
14.6 Principles of Good Governance and Management

14.7 Let Us Sum Up
14.8 Glossary
14.1 INTRODUCTION
In the earlier units we have studied about nutritional problems and various strategies
to combat nutritional problems. We have also studied about various nutrition policies
and programmes designed to combat nutritional problems. Now, we need competent
and skilled staff who can design and manage these programmes in the field. However,
recruiting and training of these staff is a big task and a very complex one too. We need
people who recruit and train these specially skilled staff. This is where the role of
personnel management comes in. In this unit, we will study about the role and functions
of personnel managers, who are responsible for recruiting and give training to the staff
required to manage the programmes designed not only by government but also NGOs
and international and bilateral agencies. We will also learn about needs assessment of
the communitites since needs assessment is the first step to design a programme. We
will also take you through the steps of planning, implementing, and evaluating a public
nutrition programme. Finally, we will end the unit by discussing the importance of good
management and governance to achieve the desired results in the communities.
Objectives
l discuss the concept of programme management and administration,
l explain the importance, advantages and skills required of personnel management
by those working in government, non government and international agencies,
l elaborate the techniques of conducting situational analysis/need assessment,
316
l describe the various steps required to plan, implement and evaluate a public Programme
nutrition programme, and Management and
Administration
l discuss the importance of good management and governance to achieve the goals
of the public nutrition programmes.
We will begin our study by explaining the concept of programme management and
administration.
14.2 CONCEPT OF PROGRAMME

MANAGEMENT AND ADMINISTRATION
You must be wondering what do we mean by programme management and
administration? In Unit 10, we learnt about nutrition policy, various nutrition programmes
and their implementation. These programmes have to be managed by government or
Non Government Organizations (NGO’s), and more so, they have to be managed
systematically and efficiently, if we really want to see an improvement in nutritional
status of people. For managing these programmes systematically, we need to follow
principles of good management. Before we do that, we need to understand what
management is. So,we will briefly review what management is. We will then review
the principles and functions of management. We will also review what we mean by
administration as it applies to public nutrition programmes. Let us try to understand
what we mean by management.
Management has been applied since the beginning of civilization, whenever people
have worked together in groups, whether it is to grow crops, to buy and sell or to
arrange for an event etc., there has been management. What does management
mean? It simply means getting things done. It means committing to purposeful action
or achievement and not just action for its own sake. Thus when applied to programming,
it means we decide what we want to achieve i.e. objectives are specified and achieved.
A public nutrition programme requires many resources in terms of human, materials
and equipment etc. Thus, programme management, in this context, can be defined as
getting people to work harmoniously together to make efficient use of resources
to achieve the objectives.
Management consists of many functions which are derived from six principles of
management. These are:
1) Management by objectives
2) Learning by experience (feedback)
3) Division of labour
4) Delegation
5) Substitution of resources, and
6) Shortest decision path
A public nutrition team has three main functions of management. These are planning,
implementation and evaluation of public nutrition programme.
Let us see how we can derive these three management functions from the principles
of management as discussed above.
Planning function: Planning function of management is derived from the first principle
i.e. principle of management by objectives. This principle requires the specifications
of what and how much is to be done, and where and when it is to be done. Each of
these questions needs one or more planning decisions. Thus, the sum of these planning
decisions constitutes the planning functions of management of public nutrition team. 317
Public Nutrition Implementation function: The implementation function is derived from the principle of
delegation. This principle is concerned with authority and responsibility i.e. with
functional relations between people working together to achieve some purpose. The
types of decision involved are concerned with organization of working relations so as
to ensure effective and efficient work i.e. implementation.
Evaluation function: The evaluation function is derived from the principle of learning
from experience. Applying this principle to programme management requires the analysis
of gaps between desired results and actual results, or achievement, and the use in
decision-making of the information obtained from the analysis. This is, in other words,
a measurement and a judgment of performance, or the evaluation function of
management, that contributes greatly to the success of a public health and nutrition
team. In this unit, we will study in detail about these management functions.
Let us now learn about administration. The term administration refers to the direction
and management of affairs, and to the activities of groups cooperating to
accomplish common goals. Administration, therefore, is a wider term and encompasses
such activities as spelling out policies and objectives, establishing suitable organization
structures and providing necessary resources for realization of objectives. Thus,
administration determines the organization and management uses it. Administration
defines the goals and management strives to attain it. Management is an executive
function that is primarily concerned with carrying out the broad policies laid down by
administration. Figure 14.1 depicts the difference between administration and
management clearly which shows that administration is a determination function carried
out by top people in the hierarchy of the system, while management executes as is
decided by administration.
ADMINISTRATION  Determination function
Top hierarchy
MANAGEMENT  Executive function
Middle and lower level hierarchy
Figure 14.1: Difference between administration and management
Thus, in public nutrition programme, we have policy makers at higher levels in Ministries
and the Specialized Departments under the Ministries who are involved in making
decisions about nutrition policy and programmes, their organization and sources and
amount of funding. Management of these programmes is then handed over to various
functionaries at the center, state, district, block and village/panchayat level for planning,
implementing and evaluation.
You know by now that the management functions as discussed earlier i.e, planning,
implementing and evaluating a public nutrition programme essentially involve working
and dealing with people. Getting the work done through people means that people must
work, perform certain activities and tasks to reach certain ends and objectives. This
also means that people who do these tasks possess certain technical skills and
competencies so that they are able to accomplish these activities and tasks successfully.
Developing an organization structure for a public nutrition programme then becomes
a carefully thought out and planned process and again requires the skills and competencies
of certain specialized people. This is where the role of personnel management comes
in. Let us now discuss in detail what is personnel management and what are the role,
skills and functions of a personnel manager.
318
Programme
14.3 PERSONNEL MANAGEMENT Management and
Administration
Personnel management in a public nutrition programme has a special role to identify,
recruit, train and maintain the staff responsible for nutrition programmes. We
discussed above that we need specially qualified and skilled staff to manage the
nutrition programmes. So the people who will recruit, train, and maintain these staff in
an organization need to possess certain skills and perform certain roles in achieving this
task. This is where the role of a personnel manager comes in. Earlier “ liking people”
appeared to be a sufficient qualification to become a personnel manager. Presently,
however, preference to work with people rather than objects is still important but
personnel management has become one of the most complex and challenging fields.
It requires the skills to meet the demands of an employer, as well as, the employee
and society in general. Society at large requires its human resources to have vital
needs that move beyond a ‘work force status’. The employer must realize that an
employee of an organization is not only an employee but also a human being and a
citizen of the society/country in which he/she works. Thus, the personnel manager has
to perform certain roles and functions which will help them to recruit, train, and
maintain staff required to manage programmes. Let us now study about the roles, skills
and functions of a personnel manager. Let us start with the role first.
14.3.1 Role of a Personnel Manager

The manager has to satisfy the top management in procuring and maintaining a work
force which will be instrumental in enhancing the productivity of the organization. He/
she also has to understand the necessity of ascertaining and accommodating to the
needs of the human beings that constitute such work force. Therefore, the job of a
personnel manager has become more challenging in recent times. It is due to the rise
of the modern labour unions, increased educational levels of the members of the
society, the increasing size and complexity of the organizations and its technology and
the demands (reasonable/unreasonable) of the less privileged segments of our
communities.
Let us now look at the skill of a personnel manager.
14.3.2 Skills Required by a Personnel Manager

The modern personnel manager requires the following skills:
1. a broad background in the fields of psychology, sociology, philosophy, economics
and management,
2. he or she must deal with situations, which often do not have right answers for
all,
3. an ability to understand not so logical demands of the employer or employees,
4. a capacity to programme one self into others position without loosing perspective,
and
5. skills in predicting human and organizational behaviour,
Having learnt about the skills required by the personnel manager, let us now look at
the functions which the personnel manager is expected to perform.
14.3.3 Functions of a Personnel Manager

If we refer to the principles of management as discussed in section 14.2 above, you
would note that the principles of division of labour and delegation apply to management
functions that deal with personal relations. These functions relate to a personnel manager
as the one who exercises authority and provides leadership over other personnel. In
addition, a personnel manager has to perform certain functions where he/she has no
authority but has been given certain specific responsibilities to perform the basic 319
Public Nutrition function, these are termed as operative functions. Thus the personnel manager has to
perform both the management and operative functions. Management and operative
functions include certain components. These are illustrated in Figure 14.2.
Functions of a Personnel Manager
Management Functions Operative Functions
Planning Organizing Directing Controlling Procurement Development Compensation Integration

Figure 14.2: Functions of a personnel manager
Let us study the components of management and operative functions in detail. We will
start with the management functions first.
1. Management functions
Within the management functions, planning, organizing, directing and controlling
are the main components. Let us look at each of these component functions,
which a personnel manager is expected to perform.
a. Planning: Planning here refers to clearly spelling out the activities and
tasks to be performed and assigning the personnel to perform them. Under
the planning function, the personnel manager has to identify a personnel
programme in advance that will contribute to the goals established for the
organization. For doing this, he needs to actively participate in the process
of goal establishment and contribute his/her expertise in the area of human
resources to this process. The planning function also includes personnel
manager to demonstrate varying set of skills and expertise while hiring staff
for government or non-government organization. For example, while planning
or hiring staff for the government, the personnel manager may require
special skills to judge attitude, commitment, efficiency, as most often in
government organization, an employee once recruited will be required to
perform functions for long periods of time with virtually no option for the
change. Similarly, in non-government and international agencies, specific
core qualifications and skills of employees may be required for doing a
specified job for a specified period of time. For this, the personnel manager
may require expertise testing the person’s knowledge and skills for specific
jobs to be done.
Next, let us look at the second component of management functions i.e.
organizing
b. Organizing: After planning for a personnel programme and establishing
the type of personnel required for recruitment, the next important function
of the personnel manager is to organize his/her work. Organizing here
means that the personnel manager should arrange the work in such a way
that the hired staff use their individual skills and talents effectively and
work is distributed evenly among them. For carrying out this function, the
personnel manager has to form an organization by designing the structure
of relationships among jobs, personnel and physical factors. This organization
is nothing but a means or a process to reach the goals set earlier during
the planning process. The manager must be aware of the complex relationship
that exists between the specialized unit and rest of the organization.
Let us look at the third component i.e. directing.
320
c. Directing: Once the plan and organization to execute the plan has been Programme
established, the next important function of the personnel manager is to give Management and
Administration
directions to staff for working in an organization. Under this function, the
personnel manager is expected to guide the people to work in an efficient
and healthy environment. In some organizations, the personnel manager is
expected to develop a policy and procedure manual which provide guidelines
for employees. The personnel manager is also expected to keep the employees
motivated to work willingly and effectively.
Let us now look at the fourth and the last component of management
functions of a personnel i.e. controlling.
d. Controlling: The management duty of the personnel manager is to observe
or control the actions of the employees. Under this function, the personnel
manager has to assure certain minimum standards by staff in an organization.
He/she has also to ensure that employees continue to work according to the
plans of the organization. Good control by the personnel manager should be
timely, simple, minimal and flexible.
With controlling component, we come to an end of our study of the management
functions of a personnel manager. We studied above that along with management
functions, certain operative functions are also basic to the job of a personnel manager.
Let us now look at the various components of the operative functions.
2. Operative functions
The operative functions of a personnel manager include procurement/recruitment,
development, compensation and integration. Let us get to know more about these
functions.
a. Procurement: The first operative function of the personnel manager is to procure
or recruit the kind and number of personnel necessary to accomplish the goals
of the organization. He/she is expected to determine human resource requirements
and their recruitment, selection and placement.
b. Development: After recruitment, the personnel manager is expected to develop
or train the employees to increase their skills for their professional development,
which may be necessary for proper job performance.
c. Compensation: Under this function, the personnel manager is expected to provide
adequate and equitable remuneration to personnel for their contributions to the
organization. This requires that he/she possess special skills for job evaluation,
wage policies and wage system etc.
d. Integration: The personnel manager should be able to reconciliate effectively the
individual, societal and organizational interests for pursuing the goals of the
organization.
If both management and operative functions of the personnel manager are well
executed, the other important functions of the personnel manager are maintenance of
the work force. This requires constant communication with the employees and cares
to look after the physical conditions of the employee, such as maintenance of health
and safety of the employees.
Lastly, the personnel manager has to make plans of separation of the employees from
the organization. This includes functions such as retirement benefits, if any, lay off, out
placement, and discharge.
Thus, to sum up, personnel management is the planning, organizing, directing,
maintenance and separation of human resources to the end that individual, societal and
organizational objectives are met. 321
Public Nutrition In this section, we learnt about the importance of personnel management in public
nutrition programmes. They can provide tremendous support in recruiting, training and
retaining staff responsible to manage public nutrition programmes in government or
non-government agencies. Once we have hired the right staff with specific skills and
competencies and established an organization, the next step is to manage the public
nutrition programme. In the next section, we will study about the key management
functions i.e. planning, implementing and evaluating a public nutrition programme.
Before we move on this section, let us recapitulate what we have learnt so far.

1. What do you understand by programme management and administration?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
2. What are the management and operative functions of a personnel manager?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
3. Mention the type of knowledge and skills required for being a good personnel
manager.
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
14.4 PLANNING, IMPLEMENTING AND

EVALUATING PUBLIC NUTRITION
PROGRAMMES
In this section, we will study about how to design/plan, implement and evaluate a public
nutrition programme. A programme manager in a public health team is responsible for
improving public nutrition in his/her area. The area may be as large as a village or as
big as a district. We studied about three management functions i.e. planning,
implementing and evaluating in section 14.2 above. These concepts of management
functions are applied to public nutrition programme also. The planning function of
management in a public nutrition team deals mainly with decisions about objectives,
activities, and resources , by systematically considering what, which, where, when, and
how much and how the team would perform. The implementing function deals with
achieving and performing activities planned during the planning process. Evaluation
function is concerned with effectiveness or achievement of results and efficiency or
economic use of resources.
Thus, keeping these functions in view, major steps in planning, implementing, and
evaluating a public nutrition programme are listed as:
1. Identify the issues or health problems in the community.
2. Prioritize the issues or nutrition health problems, to identify those that the programme
will address.
322
3. Identify risk and contributing factors and set the goals and objectives for the Programme
programme. Management and
Administration
4. Determine strategies for the programme.
5. Develop the action plan and implement it.
6. Sustain the entire programme or its components.
7. Evaluate the programme.
8. Incorporate sustainability issue and the evaluation plan at the time of planning the
programme.
We will review these steps in detail now: Let us begin with the first step.
Step 1: Identify the Issues or Nutrition Health Problems in the Community
Identifying the issues or nutrition health problems in the community is the first step
of planning a public nutrition programme. Problem identification and its analysis is
required for developing goals and objectives for the programme that are realistic and
achievable. Once the goals and objectives are set, strategies for achieving them can
be determined. Resources needed for the programme and the sources to obtain these
resources, are then identified.
The nutrition and health problems in a community are identified through the process
of needs assessment or situational analysis. You must be wondering what needs
assessment is. Needs assessment describes a process by which the assessment of
the current situation in the community is undertaken, value-based judgements
regarding the preferred or desired situation are reached, and some determination
of the priority status of local needs is made. We will read in detail about it in the
next section 14.5. Needs assessment helps the community to reflect upon their problems
and bring forth issues which need to be addressed. In fact, needs assessment is the
first step in designing a public nutrition programme and gives a good indication of the
priority needs of a community. It is important to remember that needs are always
thought of differently by different people. For example, if you see a mother with a sick
child, you may think that her need is to take the child to the doctor. However, she may
not feel the same need as yours. Her need may be to go to work and earn some
money. Thus, while undertaking a need assessment, it is important to consider that
needs will be thought of differently by different people. For this reason, needs are
sometimes classified as:
1. Normative Needs
2. Felt Needs
3. Expressed Needs
4. Comparative Needs
We should understand the different types of needs so that we can identify the issues
appropriately for programme design. Let us study about each type of need in detail.
1. Normative Needs
Normative needs are based on the opinion and experience of ‘experts’ according
to current research and findings. For example, nutrition and health experts
consider that even mild to moderate malnutrition is detrimental for health. Therefore,
a primary health care provider may strongly devise strategies for its prevention
and control. Similarly, the Health Ministry recommends that all children be
vaccinated against specific diseases. Also, assuming that during needs assessment,
we identify that many children in a particular population of children were not
immunized against these diseases. This situation would indicate a need for an
immunization programme.
323
Public Nutrition 2. Felt Needs
Felt needs are those needs that groups or individuals say they want, or the
problems that they think need addressing. For example:
l Many women from a community feel that there is lack of safe drinking
water or irrigation facilities for their lands. The community may decide to
address this issue by informing their elected local leaders to solve their
problem.
l The community demands more variety in ration available at the ration shop.
The government may decide to look for reliable and cheaper sources of
different varieties of ration to satisfy the demand.
3. Expressed Needs
The number of people using community facilities and services shows expressed
needs. For example:
l Long queues at the community taps or pumps may express a need for more
community taps.
l Very few people using the community health facilities may express a need
for alternative activities.
4. Comparative Needs
Comparing what is available to one group of people with what is available to
another group shows comparative needs. For example:
l During droughts and natural calamities all groups of people may want equal
access to the government services as compared to normal times when only
marginalized population or most vulnerable population may be utilizing
government services.
When determining the needs of a community or a group, we should focus on a range
of needs and use variety of tools to determine each type of need. The tools which
can be used for needs assessment have been discussed in the next section.
Thus, understanding about different types of needs while doing needs assessment, can
help us to channelize our resources more effectively and efficiently in programme
design and implementation.
Once we conduct needs assessment, we should always share the results with the
community. This sharing process is a key part of the planning process. This process
will:
l raise community awareness about the issues and possible underlying causes,
l stimulate discussion about ways to address the issues, and
l get the community more involved in planning and decision-making about the
programme.
Now that we have identified the needs and decided on what issues/problems exist in
the community with their participation, we may get a long list of issues/problems to
be addressed. But it is not feasible to resolve all their problems, so we may want to
look at just few important issues. Thus the next step becomes to prioritize issues from
the assessed needs/problems.
Step 2: Prioritize Issues or Nutrition Health Problems
At the end of Step 1, the programme team would have identified a list of major issues
and potential target groups for the programme. There are always competing needs or
324
issues in any community. Limitations such as time and resources mean that not everything Programme
can get addressed. Issues would need to be prioritized. Needs and priorities you have Management and
Administration
learnt in step 1 can vary from individual to individual, family to family, group to group.
It is important to work out criteria to sort out which issue the programme will address.
For doing this, we may ask some questions to ourselves and key stake holders, which
may help to expand group thinking and discussion on prioritizing needs. We have
divided these questions into five broad categories.
a) How many people in the community are concerned about the issue?
b) How serious is the issue or problem?
c) How easy is it to change?
d) What kind of resources will it need?
You would realize that within each of these questions, there may be more issues which
would require thinking. Let us review the list of issues under each category. We begin
with first question.
a) How many people in the community are concerned about the problem?
To be able to find out the answers to this question, very often the programme team
may need to find out the following:
l What is the felt need of the people and how has this been demonstrated?
l What kind of community support is necessary for a programme to succeed?
l Who needs to be involved? Are the ‘right’ people concerned and involved?
l How much support does the programme or activity really have?
Once the team has determined the answers to these smaller issues, it can get the
answer of how many people are concerned about the problem.
Let us now look at the second question.
b) How serious is the issue or problem?

This question can be divided into smaller set of questions whose answers we have to
determine from the people.
l Is the problem affecting a lot of people?
l What proportion of the population does it affect?
l What sort of damage is it doing to people of different socioeconomic/ethnic class
on physical health, mental health and other aspects of life?
l What will happen if nothing is done about the situation?
Having determined how many people in the community are concerned about the
problem and how serious is the problem, the next thing is to find out how easy it is
to change.
c) How easy it is to change?

We will be required to answer some smaller questions in order to answer this
question.
l What has already been tried or done which may affect a new approach to
the issue or problem? Bad past experiences can and do affect community
motivation to get involved.
l How much assistance will people need to change the situation?
l How likely are they to have success? What are the barriers and what are
the helping factors (enablers)?
l How many other things need to change before this particular problem changes? 325
Public Nutrition Thus after determining, how easy or difficult it is to change the situation, it will help
us identify the type and amount of resources. So we come to the next question.
d) What kind of resources will it need?

We will have many questions related to the type and amount of resources. Seeking
answers to these questions will help us decide a very important component of the
programme. i.e. resource allocation, without which we really cannot achieve our goals.
l Human Resources
--- What kinds of human resources will it need initially and in the long term?
--- What human resources are available within the community?
--- How much training and external support will be required?
--- Will there be a need to involve people outside the community?
--- How easy will it be to get outside help if needed?
l Funding
--- How much will different options cost?
--- Where will the money come from? How long will it take to receive it?
l Materials and equipment
--- What kind of materials will be required? What materials are available
locally that could be used?
--- Is any equipment needed? Are any buildings required?
Thus, having identified the problems, seriousness of the problem and the resources,
we still need to answer some more questions related to implementation. These are
listed as follows.
e) Some questions to answer before implementation

l Did a number of community members participate in identifying the problem?
l Have a wide range of people and organizations been consulted?
l Has all the relevant information been reviewed (literature, community profile)?
l Did people have accurate information about the problem, causes and possible
solutions?
l Was this information used in the discussions and consultations?
l Has the information been fed back to the wider community?
l Has the programme team got the information that it will use as baseline data?
Thus we can find out the answers of these questions from the community and
government and non-government members who have an interest in solving the problems
of the community. We can then prioritize the issues/problems to be addressed during
programme implementation.
We mentioned “funding” above for identifying the kind of resources. Funds or monetary
resources are very important criteria for prioritizing the problems identified during
needs assessment. This determines to a large extent what issues we can address and
what we can’t. You should know, how we can obtain resources for our programme.
Generally, there are two ways to fund the programme: We can:
l use resources available locally, and
l seek funding from government, non-government organizations, bilateral agencies
etc. These funds will probably be tied to priorities based on ‘normative needs’.
However, a programme funded according to these needs can include other
326 community identified priorities.
Thus we saw how we can prioritize the issues/problems of the community. Community Programme
action can be mobilized through confidence gained by participating in successful, well- Management and
Administration
planned programmes. There are numerous examples of situations where community
members have taken on an idea from outside the community and become more fully
involved in controlling and participating in activities. Third step is how to identify risk
and contributing factors and set the goals and objectives.
Step 3: Identify Risk and Contributing Factors and Set the Goals and
Objectives for the Programme
After we prioritize the problems, we need to analyze the problem to identify the risk
and contributing factors and set the goals and objectives for the programme. Let us
first understand what we mean by risk factors and contributing factors.
‘Risk factors’ are any aspect of behaviour, society or the environment that are directly
linked to the health problem. Risk factors lead to or directly cause the problem. Note
that some risk factors can be modified, while others are not modifiable. For example,
smaller landholdings of a farmer may be a risk factor for poverty and are not modifiable
under the issues addressed by public nutrition programmes, while direct exposure to
bacteria and germs (environmental) may be a risk factor for diarrhoea which can be
changed.
‘Contributing factors’ , on the other hand, are any aspect of behaviour, society or the
environment that leads to the development of risk factors. Contributing factors enable
or reinforce the risk factors. They can relate to individual, financial, political, educational,
environmental, or other issues.
Some examples of contributing factors are:
l lack of knowledge about balanced diets (educational) and wrong beliefs and
habits are both contributing factors to the risk of malnutrition in children, and
l poor housing conditions (environmental) and lack of home hygiene (behavioural)
are both contributing factors to the risk factor ‘exposure to bacteria and germs’
We need to analyze the problems to determine the risk factors and contributing factors.
Let us see how problem analysis is done.
Problem analysis
Addressing a problem successfully will require the programme to focus on the underlying
causes or issues that led to the problem in the first place. In other words, the goal and
objectives of a programme need to relate to the underlying causes or issues. Developing
a clear and organized goal and objectives that relate to each other requires some
critical analysis of the problem. The way to analyze the problem is to first state what
it is and then ask questions like ‘why’ and ‘how’ to identify the causes of the problem.
At this point, you may need to search through research reports, articles and books to
see what others have discovered about the problem.
The issues or problems targeted by the nutrition health programme will probably have
more than one risk factor. The programme will aim to make a change in one of these
risk factors as stated in the programme goal. Analysis of the nutrition health problems
helps the programme team to identify what complementary programmes are needed
(either planned by the team or others) to change the other risk factors. Based on the
problem analysis, the team should develop the goals and objectives for the programme
which is discussed next.
Developing the programme goal and objectives

The goal is about making changes to the risk factor addressed by the programme.
The goal indicates what the planned, long-term outcome of the programme is.
It is also intended to inspire, motivate and focus people and encourage team cooperation.
327
Public Nutrition For example, we can have the goal “Reduce prevalence of diarrhoea in preschool
children’’.
Objectives state what changes the programme will make to the contributing factors.
The objectives indicate what the impact will be on the contributing factors during the
time frame of the programme and finally the objectives should indicate the desired
changes in the programme. An example of objective would be: X% of families are
educated about improving home hygiene in 2 years. Well written ‘goals and objectives’
would state who will achieve how much of what and by when. Developing a clear,
achievable goal and objectives would also require good baseline data, which can be
available either through primary data collection or secondary sources.
While there may be many contributing factors, it is advisable to focus on three or four
factors only, in order to keep the programme manageable and achievable. Perhaps
there are other people in the community willing to tackle the other contributing factors.
Thus before we proceed further, we need to ensure the following points:
l Are the risk factors directly linked to the priority nutrition health issue/problem?
l Does the goal address one of the risk factors?
l Do the contributing factors relate to the risk factors chosen?
l Do the objectives address the contributing factors?
l Do the risk factors and contributing factors relate to the situation of the target
group?
l Are the goal and objectives specific and measurable (who will achieve how
much of what and by when)?
l A worksheet that can be used for problem analysis can be prepared. It is part
of the documentation of a full programme plan.
After we have identified goals and objectives, we need to determine the strategies to
realize these goals and objectives. This brings us to the next step i.e. determine
strategies.
Step 4: Determine Strategies

After the goals and objectives are identified, then the strategies are determined.
Strategies describe what the programme team will do, to try and make the changes
required to achieve the objectives. For example, we could conduct trainings, mobilize
the community etc. in the programme to realize our goals and objectives.
Some examples of strategies are given in Box 1.
Box 1 Examples of Strategies
--- Conducting nutrition health sessions --- Meeting with parents, other family
about causes and consequences supporters, grass root level nutrition
of malnutrition health workers
--- Making behaviour change --- Pasting educational materials at
communication (BCC) materials important community points
--- Organizing programmes to promote --- Training in how to prepare
the consumption of variety of foods budget
--- Supporting a nutrition health grass --- Making policies for joint
root team collaborations to reach common
goals
--- Developing a nutrition policy for --- Organizing an advocacy programme
malnutrition control for policy makers
328
Again, we can ask the key stakeholders and ourselves certain questions. Finding Programme
answers to these questions would help us to determine strategies. These questions are: Management and
Administration
l How will we achieve our objectives?
l What are the most useful and appropriate strategies for the target group?
l Will interested community members be involved in carrying out the strategies?
l Who else might have ideas that could help us?
l Is there anything else that we need to find out first?
l What strategies have been used in the past to address this issue?
l How well did the past strategies work? Were there any problems? What can we
learn from them?
l In general, what resources are needed for each strategy? Do we have them or
can we get them?
l Were interested community members/target group members involved in deciding
on the strategies?
l Will the strategies be appropriate for the target group?
l Do the strategies reflect the essence of the government policies?
l Do the strategies promote and respect cultural practices?
Therefore, we have seen that the process for planning a programme begins with the
big picture of an issue or a problem. It is an analysis of the big issue/problem that gives
the framework for developing the plan - from the long term goal, to more specific
objectives, then to the actual strategies, and finally the detail of individual actions. So
now the next step is develop an action plan and implement the programme. Let us
learn how.
Step 5: Develop an Action Plan and Implement it

Once the strategies of the programme are determined, the programme team can write
the action plan. The action plan includes all the specific activities, large and small, that
will need to be done to implement each of the strategies. It should also specify who
will carry out these activities, when they will be completed and how they will be
evaluated.
The more detailed the strategies, the easier it will be to accurately identify all
the activities to be done. If the programme is large, with many stages, it may not be
possible to detail all the specific activities at the beginning of the programme. If the
programme objectives must occur in a special time sequence, wait for some early
work in the programme to be completed before working out the detail of the later
phases.
Detailed documentation of the activities, responsibilities and time frames will assist
each team member to plan his or her part of the programme. Detailed documentation
is also important for maintaining accountability within the team and between the team
and the community or funding agency.
The action plan will also list the resources required to do the programme successfully.
Resources will be required throughout the whole programme, from need assessment
through putting strategies into action to final report writing. Resources can include
human resources, financial resources, materials, equipment and venues. The best
resources for a community nutrition health programme are those that come from the
community or are developed by interested community members. Programmes carried
out using a community development approach build on existing skills and support people
to develop further skills.
329
Public Nutrition If programmes use human resources from outside the community all the time, community
members may begin to feel that they have no resources of their own. Such an
approach could make the community dependent on outside sources to solve their
problems, hence will not be sustainable. We should use the resources of the community,
whenever possible. It will build community confidence, self-reliance and enthusiasm
and empower them to solve their own problems. Answering the following questions
can help identify resources:
l Who can assist in putting the strategies into action?
l What skills are there in the community which can be drawn on and built upon?
l What venues or places need to be organized? Are they appropriate for the
activities? Will people feel comfortable there?
l What equipment is needed? Is it in the community? Will the programme team
need to borrow or buy equipment?
l Do we need any money for the programme? Can the local self government,
community groups/ members budget or fund it?
l Where will we get the educational resources?
l What resources have worked well in the past with the target group?
Before proceeding to implement the programme, we can try to get the answers for the
following questions:
l Have all members of the programme team been involved in developing the action
plan?
l Are the activities achievable with the current resources (time, money, personnel,
equipment, and so on)?
l Does the programme use community member’s skills, knowledge and resources?
l Do people know what their responsibilities are?
l Are they confident, willing and able to carry them out?
Once we have answered the above questions, we can go ahead and implement the
programme with the help of government, non-government and other partners as stated
in the action plan.
Once the programme has been implemented, it is very important to ensure that the
programme continues as long as it is planned for and even thereafter. Sustaining the
programme is an important aspect. Let us see what strategies can be adopted to
sustain the programme.
Step 6: Sustain the Programme

Planning for sustainability means thinking of ways to keep the programme (or important
parts of it) going after its official end. It then becomes an ongoing part of community
activity.
Many factors can threaten the sustainability of the programme. Programme teams
need to be on the lookout for these factors and have a plan for dealing with them.
Sustainability needs to be considered from the initial planning stages of a programme.
Again we need to answer certain questions in collaboration with key stakeholders to
address the issues of sustainability
These questions are:
l How will the programme team assess the ongoing need for the programme?
l Are community members involved in the management of the programme?
l What skills and facilities are required by the community to manage and maintain
330 the programme?
l Is training needed? Is it available? How will the community access it? Programme
Management and
l Who can continue the work? Administration
l How will the community secure ongoing access to financial and other resources
to do the programme?
l How will interest, commitment and ownership be maintained?
l How will the direction and focus of the programme be maintained?
l Is there further support required from outside the community?
l If yes, how will the community secure this outside support?
l Is there enough flexibility in the programme to respond to changing circumstances?
We should know that people will be more likely to keep the programme going if they:
l feel that the programme is theirs and that they have control over it,
l are working together well,
l can see positive changes happening because of the programme,
l are learning new skills and their confidence is increasing,
l get recognition for their work,
l understand that all elements of the programme are suitable and relevant to them
- language, style, pace of work, strategies, evaluation methods, resources,
l believe that the people from outside the community, who are working on the
programme, are credible to the community, and
l know that accountability to the community has been built into the programme.
Thus we see that for sustainability of the programme, we need to plan for all the above
factors from the very beginning of the programme, otherwise we will not be able to
sustain the progamme. Once the programme is being implemented, we would always
want to know how it is going. For this we conduct an evaluation of the programme.
We will discuss it in detail in the next step.
Step 7: Evaluate the Programme
To evaluate is simply defined as to judge the value of something. Evaluation is a type
of research that is required to be planned right from the beginning of the programme.
It is important to incorporate evaluation into the planning process so that the information
required for the evaluation can be obtained during the programme. If evaluation is not
planned until the end of the programme, valuable information may have been lost.
Before planning the evaluation, the programme team needs to consider some basic
questions:
l Who are we evaluating for?
l What do they want to know?
l What do we want to know?
l How are we going to find out?
l What does the information mean?
When the programme takes a community development approach, then community
partnership in evaluation means that people take a significant role in deciding when,
how and what to evaluate. Community members need to be involved in selecting the
methods to be used in collecting and analyzing data, in preparing reports, and in
deciding how to use the results and put their recommendations into practice.
It is useful to prepare a written plan for the evaluation in the same way as it is
prepared for the programme (e.g. goals, objectives, strategies, activities, resources and
timeframes), the eight stage model of evaluation is one way to plan the evaluation. 331
Public Nutrition It offers specific questions to focus the planning of the evaluation into manageable
stages.
Box 2 depicts the eight stage model of evaluation, with different stages of planning an
evaluation, right from what to evaluate to designing strategy for evaluation and
reassessment for improving the programme .
Box 2 Eights stage model of evaluation plan
The eight stage model of evaluation plan include:

1) Focus of evaluation:
l What is being evaluated and why?
l Who needs to know?
2) Formulation of questions for evaluation:

l What are the key issues that need to be evaluated?
l What will be the lessons learned from evaluation?
3) Designing strategy for evaluation:

l Information to be collected from where, when and how
4) Coordinate plan for evaluation

l Who will implement the plan of evaluation?
l How evaluation should be done?
5) Collection of data
l Evidence of the impact of the programme
l Evidence of best practices/failures of the programme
6) Analyze data
l Major findings
l Reasons for success/ failures
l Lessons learnt
7) Reporting
8) Reassessment
l How to improve the programme for better impact
Evaluation is done mainly for the following reasons 1) To determine if the programme
objectives have been met 2) To assess how the strategies are working and make
modifications if required 3) To provide feedback to key stake holders, and 4) To assess
best practices and failures. Thus evaluation is a carefully thought out planned process.
It needs to be incorporated into the programme from the very beginning.
We discussed about how to plan, implement and evaluate public nutrition programme.
You may recall that in the beginning of this section, we stated that needs assessment
is the first step of designing a programme. It helps the community to reflect upon their
problems and bring forth issues that need to be addressed. We also stated that when
determining the needs of a community or a group, we should focus on a range of
needs and use variety of tools to determine each type of need. In the next section,
we are going to discuss the kind of tools or techniques we use in assessing the needs
332 of the community. But, first we shall review what we have learnt so far.
Programme
Check Your Progress Exercise 2 Management and
Administration
1. What are the steps for designing a nutrition health programme?
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2. What do you understand by the term sustainability and list points that have to
be kept in mind while designing sustainable programmes?
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3. What are the steps involved in the process of evaluation?
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14.5 TECHNIQUES FOR CONDUCTING

SITUATIONAL ANALYSIS NEEDS
ASSESSMENT
In this section, we would learn about various tools or techniques for conducting needs
assessment. But you must be wondering what are community needs? What is needs
assessment? Why do we do it? So before we learn about techniques to conduct needs
assessment, let us answer some of these questions first.
What are community needs?

Community needs can be many, but here, we will limit ourselves to nutrition and health
related needs. Thus, nutrition/health needs are understood as being those states, conditions
or factors in the community that, if absent, will prevent people from achieving complete
physical, mental and social health. This would include such things as minimum provision
of basic health services and information, a safe physical environment, good food and
housing, productive work and activity, and a network of emotionally supportive and
stimulating relationships.
What is needs assessment?

The concept of community needs assessment/situational analysis describes a
process by which the assessment of the current situation in the community is
undertaken, value-based judgements regarding the preferred or desired situation
are reached and some determination of the priority status of local needs is made. 333
Public Nutrition The accurate appraisal of the current situation is an important element in this process.
In most instances, this requires the collection of first-hand information from relevant
audiences.
Why do we conduct needs assessment?
Needs assessment helps the community to reflect upon their problems and bring forth
issues which need to be addressed. It is the first step in designing a public nutrition
programme. Needs assessment provides an opportunity for the community to become
involved in the planning from the beginning. It helps with allocating resources and
making decisions about where to start with health promotion work. Some of the
information gathered during the need assessment may be used to collect baseline data
to decide on the important indicators, which will help to evaluate the impact of the
intervention programme.
Let us now study different techniques for conducting needs assessment or situational
analysis.
Techniques for conducting needs assessment or situational analysis
There are different techniques/approaches for conducting needs assessment. We will
discuss the commonly utilized approaches for gathering new information on the needs
of community members These are:
l Key informant approach
l Public forum approach
l Nominal group process
l Delphi technique, and
l Survey approach.
Each of these techniques/approaches represents a unique method for gathering
information on the concerns of community. Which technique should you use in your
need assessment activities? We can decide that once we review these techniques. The
quality of information about a community is only as good as the technique or combination
of techniques used. A single technique may be too narrow in the information it provides
and using too many methods may be costly in terms of time and money. Different
techniques are appropriate for different needs. We should analyze the situation and the
most significant questions being asked and then weigh the advantages and disadvantages
of several techniques. Sometimes a combination of several techniques will provide a
reasonable picture. Re-examination of the “needs assessment process” may be done.
This can be done by a logically arranged, step-by-step procedure for conducting a
needs assessment. For example, the “need assessment process” includes careful
attention to the purpose of the study, as well as, determination of whose needs are to
be assessed. These two steps by themselves can help guide you in the selection of
a primary data collection technique(s). The financial, human, and other anticipated
resource requirements associated with the technique should be taken into consideration
as well. We will now discuss each approach in detail. We will study about the purpose,
type of people from whom the information is collected, implementation, advantages
and disadvantages of each approach. Let us begin with the key informant approach.
14.5.1 Key Informant Approach

The purpose of this approach is to collect information from those community members
who, because of their professional training and/or affiliation with particular organizations,
agencies, or associations, are in a prime position to obtain a more comprehensive
viewpoint of what the needs facing the community are. After the data from the
questionnaires or interviews are collected and organized, the sponsoring group may
want to give “feedback” about the findings of the survey to the key informants, who
participated. In this way, the sponsoring group may help stimulate additional insights
334 into public needs.
Who are the types of key informants? Programme
Management and
The types of key informants are: Elected officials (e.g. mayors, commissioners, Administration
panchayat raj leaders, etc.), key persons in institutional areas of the community (e.g.
religious leaders, health/ nutrition sector officials, administrators, etc.), agency
administrators (e.g. social sector departments), leaders of public service organizations
and professionals in specific service areas (e.g. physicians, public health specialists,
nutrition specialists and faculty, etc.).
How to implement the key informant approach?

We implement it through the following steps:
l Compile a list of “key informants” by name.
l Decide how you want to collect information from these key informants via
questionnaires, interviews, meetings or (perhaps all of them).
l Construct a brief questionnaire and/or interview form which can be used to obtain
the information you need.
l Gather data.
l Organize data.
l Interpret data.
l Schedule a meeting with key informants.
Share the findings of your study with key informants. Discuss your interpretations and
their interpretations of the data. The instrument administered to key informants should
contain questions that will successfully elicit the type of information needed to identify
community needs. For nutrition programmes this might include the following types of
questions: (1) the key informant’s perceptions or attitudes of general community needs,
or needs that might exist within specific areas of the community (e.g. the local economy,
literacy levels, gender equity, nutrition or health services), (2) key informants, perceptions
(or attitudes) concerning what is currently being done about meeting those needs, and
(3) his/her ideas as to what should be done about resolving needs that remain unmet.
As a means of ensuring that a good cross-section of key informants comprises your
study, it might be useful to also include questions concerning the background
characteristics of key informants (e.g. age, sex, race, and of residence).
What are the advantages of key informant approach?

The advantages are:
l It is one of the easiest and least expensive ways to systematically assess needs.
l It gives opportunity to establish rapport and trust and thus obtain the insiders’
view.
l It provides depth of information concerning causes or reasons.
l It permits continual clarification of ideas and information.
l It can be combined effectively with other techniques.
l It permits input from many individuals with different perspectives on the needs of
the community.
l It can be implemented by community volunteers, thereby building community
involvement and awareness.
l It does not involve the high cost of printing and data analysis.
l It may help initiate (or strengthen) the lines of communication among service
organizations, agencies, and associations.
335
Public Nutrition l Discussion of the findings with the key informants promotes insights for all
concerned.
l The data collection instruments are usually easier to construct than those associated
with the Survey Approach. Let us also look at the disadvantages.
What are the disadvantages of the approach?

The disadvantages are that:
l The information derived from this technique may represent a “biased perspective”,
since the information is typically elicited from “providers of services” (as opposed
to the “consumers” of services).
l The information derived from key informants often represents the perspectives
(and biases) of the organization, agencies, and associations with which these
informants are associated.
l A group meeting held to “feed back” the findings of the study to the key informants
may only work to rigidify a “provider” bias in terms of clarifying what the real
needs are.
l Personal relationships between researchers and informants may influence type of
data obtained.
l Jealousy and resentment amongst other community members whose opinions are
not solicited may develop.
l Should be combined with other methods, because representation of total community
is difficult to achieve.
l Few people can sense all the needs and concerns of all people in a community,
the perspectives of those who are less visible may be overlooked.
Sometimes to overcome some of the disadvantages mentioned above, an expanded
key informant approach is also used. Thus, one of the weaknesses associated with
the traditional key informant approach is the persons identified as “key” may not
always hold formal positions in the community, nor wield a substantial amount of
power and influence. The “expanded key informant approach” is designed to capture
some of those individuals who may be omitted using the traditional approach but who
occupy positions of leadership in the community. One method that can be used to
identify these people is to select five individuals who hold official positions in the
community (e.g., sarpanch of the village, grassroot level programme functionaries and
school teachers etc.) and ask each of these persons the following concerns/ issue(s)
which is (are) being considered. These are:
l Name five to ten individuals who you feel are knowledgeable about this (these)
issue(s) in a particular community.
l Compile the list of persons mentioned.
l Take the most frequently mentioned persons on the list and ask them to complete
the same questionnaire or interview that the key informants (who hold formal
positions of authority) have been asked to complete. In some cases, key informants
holding formal positions will also appear on this latter list. If time and resources
permit, ask these persons to identify the five to ten people who they believe are
most knowledgeable about the issue or issues in question. You will notice that at
some point along the line, an increasing number of repeat selections will appear
on your list. You can stop the process at this point and ask the most frequently
mentioned persons to respond to the key informant questionnaire or interview.
336 We will now discuss the second approach. i.e Public Forum Approach.
14.5.2 The Public Forum Approach/ Focus Group Discussions Programme
Management and
The purpose of this approach is to elicit information from a wide range of community Administration
members concerning issues and community needs via group discussion taking place at
a series of public meetings in the community. Under this approach, one or more
organizations, agencies, or associations sponsor a series of public meetings (forums)
where the participants discuss some of the needs facing the community, the priority
needs are, and what can be done to meet these priority needs.
Who should Attend these Forums?
Generally open invitation is given to encourage all members of the community to
attend. Special invitation is given to “key informants,” such as those types previously
considered under the Key Informant Approach.
How do we implement the Public Forum Approach?
The steps for implementation are:
l Develop a list of discussion questions/checklist that will serve as the basis for
group discussion. Such questions as: What are the most important needs facing
our community? Why are these needs important? What have we done to help
meet these needs in the past? Where have we failed in the past in our attempt
to meet these needs? Are the needs broad enough yet important, so that most
community members (and those participating at the forums) should feel free to
address the issues without too much difficulty. However, public forums are probably
most useful where specific issues and needs are being addressed.
l Select a strategically located place for the initial meeting. Try to select a meeting
place that you feel will be conducive to the open interchange of ideas. Large
assembly halls, for example, are not usually the most appropriate settings for open
discussion. Also, select a site that is geographically and socially acceptable to all
segments of the population
l Publicize the purpose, data, and place at which the forum will be held. Use media
as much as possible.
l The group sponsoring the initial forum should take the initiative in conducting
the first meeting. A person representing the group should be responsible
for communicating the purpose of the forum to those present and what
the meeting hopes to accomplish. Another person representing the sponsoring
group should be responsible for recording ideas and suggestions presented at the
meeting.
l After stating the purpose, objective, and “groundrules’’ for the initial forum, the
discussion leader should pose the questions prepared in advance to the audience.
Encourage the open discussion and interchange of ideas.
l If the participants are on the right track, you will find the recommendations for
topics to consider and/or directions to consider for possible next meetings will
“come from the floor. If this occurs, the convener should make sure an “adhoc”
committee of participants is organized to plan for the next meeting.
l Make sure the recorder gets the names of all the participants so that they may
be personally contacted prior to the next forum.
l Recognize that unlike the other needs-assessment approaches discussed thus far,
you will probably need to “play it by ear” more with the Public Forum Approach.
Be well prepared for the initial meeting. Then let the participants join with you
in planning for future meetings. Your goal is to learn from them by permitting them
to get involved in the needs assessment process.
337
Public Nutrition What are the advantages of this approach?
The advantages of this approach are:
l The approach offers a good way to elicit opinions from a wide range of the
community members.
l It provides an opportunity for citizens to actively participate in the needs assessment
process.
l Participants in the forums may offer able assistance to decision makers after the
need assessment process is completed.
l It often contributes to enhancing the lines of communication between the “providers”
and “consumers” of services and programmes.
l This approach is perhaps the least expensive of all the systematic needs assessment
approaches.
l It is also one of the easiest to implement.
l It can provide a quick, intensive picture of community concerns.
l The approach gives community issues broad visibility.
l It is useful to identify problems, assess needs, or to suggest questions requiring
further study.
l The design of the approach is flexible and a variety of techniques can be
incorporated into it.
What are the disadvantages of this approach?

The disadvantages are:
l The burden is mainly on the sponsoring organizations, agencies, or associations to
encourage participation.
l It requires good leadership and advance organization.
l The opinions obtained are limited to those who attend, all viewpoints may not be
heard.
l The participants in the forums may actually represent a variety of “vested interest”
groups.
l Poor advance planning and advertising may result in limited participation.
l Participants in forums may use the sessions as a vehicle to publicize their grievances
(gripes) about local organizations or agencies.
l If not well facilitated, only the vocal minorities will be heard.
l A large turnout may prevent everyone from speaking and may limit time allowed
for each speaker.
l The approach may generate more questions than answers.
l The forums may bring about unrealistic expectations in the minds of the participants
in terms of what “providers” can do to help meet needs.
We will now discuss the third approach/technique i.e. Nominal Group Process.
14.5.3 The Nominal Group Process Technique

The Nominal group process is an idea generating strategy to gather individual’s ideas
in face-to-face non-threatening situations. It is intended to maximize creative participation
of group members where input from all participants is sought. The process takes
advantage of each person’s knowledge and experience. This approach is useful in
generating and clarifying ideas, reaching consensus, prioritizing and making decisions
338 on alternative actions.
How do we implement the Nominal Group Process approach? Programme
Management and
There are many variations in using the nominal group process. The following steps Administration
outline one general approach to using the process:
l If a large number of participants are involved, divide participants into small groups
of 6 to 20 persons.
l Members of the group write their individuals ideas on paper.
l Each person discusses his/her ideas and all concerns are listed on a chart or
board.
l Each idea is discussed, clarified, and evaluated by the group.
l Each person assigns priorities by silent ballot.
l Group priorities are tallied.
l There is discussion on final group priorities.
What are the advantages of this technique?

The advantages are:
l If well organized in advance, a heterogeneous group can move toward definite
conclusions.
l The technique can be used to expand the data obtained from surveys/existing
documents, or generate a more specific survey.
l It motivates all participants to get involved because they sense they are personally
affected.
l It generates many ideas in a short period of time, allows for a full range of
individuals’ thoughts and concerns.
l A good way to obtain input from people of different backgrounds and experiences
l It gives all participants an equal opportunity to express opinions and ideas in a
non-threatening setting.
l It stimulates creative thinking and effective dialogue.
l It allows for clarification of ideas.
What are the disadvantages of this technique?

The disadvantages of this technique are:
l It may be extremely difficult to implement with large audiences unless advance
preparation has taken place to train group facilitators and divide participants into
groups of 6 to 10 members.
l The process may appear rigid if group leader does not show flexibility, encourage
agenda building, and show respect for all ideas and concerns.
l There may be some overlap of ideas due to unclear wording or inadequate group
discussion.
l The knowledgeable individuals selected to participate may not represent all
community sub groups.
l Assertive personalities may dominate unless leadership skills are exercised.
l The technique may not be a sufficient source of data in itself and may require
follow-up survey, observations or documentary analysis.
Let us now look at the fourth technique the delphi technique. 339
Public Nutrition 14.5.4 The Delphi Technique
The Delphi technique is an idea-generating strategy that does not require face-to-face
interaction, although it also can be used in small groups or workshop settings. It is
more structured than the nominal group process and uses a series of questionnaires
and summarized feedback reports from preceding responses. This approach is similar
to the nominal group process i.e. in generating and clarifying ideas, reaching consensus,
prioritizing, and making decisions on alternative actions. Since face-to-face interaction
is not a requirement, the delphi technique could be used with groups that would not
ordinarily meet together. Let us look at the implementation of the technique.
How do we implement the Delphi Technique?
Many variations of the delphi technique can be designed. The following steps outline
a general approach for using the delphi technique
l Develop a questionnaire focusing on identified issues, problems, causes, solutions,
and actions. The intent is for each respondent to list ideas regarding the specified
issue.
l Distribute the questionnaire to an appropriate group of respondents.
l Each respondent independently generates ideas in answering the questions and
returns the questionnaires.
l Summarize the questionnaires into a feedback report and develop a second
questionnaire for the same respondent group. The second questionnaire should
ask respondents to prioritize or rank input from the first round.
l Distribute feedback, summary and second questionnaire.
l Respondents review feedback, report independently, rate priority ideas in second
questionnaire, and return response.
l This process is repeated until general agreement is reached on problems, causes,
solutions, and actions.
l A final summary and feedback report is prepared and distributed to respondents.
l The feedback reports throughout this process allow for the exchange of opinions
and priorities, and often result in individual changes in opinions and priorities after
respondents evaluate the general groups perspectives.
Let us study the advantages of the technique.
What are the advantages of Delphi technique?
The advantages are:
l The technique allows participants to remain anonymous.
l It is inexpensive.
l It is free of social pressure, personality influence, and individual dominance.
l It allows sharing of information and reasoning among participants.
l It is conducive to independent thinking and gradual formulation.
l A well-selected respondent panel, a mix of local officials, knowledgeable individuals,
community members, regional officials, academic, social scientists, etc. can provide
a broad analytical perspective on local problems and concerns.
l It can be used to reach consensus among groups, hostile to each other.
340 Let us look at the disadvantages of this technique.

What are the disadvantages of this technique? Programme
Management and
The disadvantages are: Administration
l The judgments expressed in the responses are those of a selected group of people
and may not be representative.
l The technique offers tendency to eliminate extreme positions and forces a middle-
of-the-road consensus.
l It is more time-consuming than the nominal group process.
l It should not be viewed as a total solution.
l It requires skills in written communication.
l It requires adequate time and participant commitment (about 30 to 45 days to
complete the entire process).
Let us study the fifth or the last approach of the section i.e. survey approach.
14.5.5 The Survey Approach

The purpose of the survey approach is to collect information from a wide range of
community members concerning issues and community needs via their responses to
specific questions. The information (data) is gathered through a carefully developed
instrument administered to individuals identified via a sampling procedure. It is
recommended that the individuals who collect this information should have at least
some training or experience in the construction of survey instruments (e.g., writing
clear and precise questions) and sampling technique (e.g. selecting the most appropriate
sampling design given the nature of the study). There are various methods of conducting
surveys. Let us look at these.
Methods of conducting surveys
Some of the methods of conducting surveys are: 1) Personal (face-to-face) interviews,
2) Self-administered questionnaires completed by respondent in groups, 3) Telephone
interviews, and 4) Mailed questionnaires. The types of surveys can often be compared
in terms of: (i) cost of implementation, (ii) time needed for completion, (iii) rate of
refusal, and (iv) the extent and type of training needed by supporting staff and decide
according to our requirements. Let us look at some of the advantages of Survey
approach.
What are the advantages of this approach?

The advantages are:
l Survey approach is perhaps the best approach for eliciting the attitudes of a broad
range of individuals.
l The data obtained are usually valid and reliable.
l The various methods discussed above may be selected in relation to desired cost
or response rate.
l It can be used to survey an entire population and provide an opportunity for many
persons to feel involved in the decision-making process.
l It secures information from individuals who may be the recipients of services
initiated as a result of the findings, thereby eliciting data from individuals who are
usually in a good position to critique the present services.
l It can be used to record behaviours as well as opinions, attitudes, knowledge, and
beliefs.
l It is an excellent technique to use in conjunction with other systematic needs
assessment techniques.
341
Public Nutrition What are the disadvantages of Survey approach?
The disadvantages are:
l This approach is often the most costly.
l To ensure statistical meaning, samples must be carefully selected.
l The results may not be valid if survey is not designed correctly.
l It may require time and expertise to develop the survey, train interviewers, conduct
interviews, and analyze results.
l It is subject to misinterpretation depending on how the questions and response
categories are designed.
l The tendency for scope of data may be limited as there may be omission of
underlying reasons, and actual behavioural patterns.
l Respondents may, at times, be hesitant to answer certain questions and may
answer what they think the authors want to hear and not necessarily how they
feel. This is a problem particularly with interviews.
l Surveys are often “one shot” affairs. For example, persons responding to a needs
survey may not be resurveyed again in the future.
l Individual’s attitudes can change rapidly due to a variety of “intervening factors’’.
Thus, in this section, we learnt about various techniques/approaches used to conduct
needs assessment/situational analysis. Thus you would note that for planning our
programme, the first thing we would have to do is to go into the community and
identify needs through the use of one or more of these methods. We can then identify
the problems in the community and plan further steps in our programme.
In the last two sections, we have discussed how to plan, implement, sustain and
evaluate a public nutrition programme. We also discussed that the programmes or
certain components of the programmes should be sustainable if we want to see the
continuous improvements in the health and nutritional status of the communities. For
successful implementation of programmes and sustainability, it is critical that these
programmes be administered properly. In other words, we need to have a good system
and mechanism in place which will provide support in programme implementation. We
also want to follow good management principles i.e. an integrated approach, so that
the programme is effective and efficient in meeting its goals and objectives. In the next
section, we will study about good governance and good management principles in
detail. Now we shall take a break and answer the questions given in check your
progress exercise 3.
1. Describe the term situational analysis/needs assessment.
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2. Enumerate the techniques commonly used to conduct situational analysis.
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342 ..........................................................................................................................
Programme
3. Answer these briefly:
Management and
Administration
a. Five advantages of conducting nominal group exercises
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b. Five disadvantages of conducting a survey in a community
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Now let us learn about good governance and good management principles.
14.6 PRINCIPLES OF GOOD GOVERNANCE AND

MANAGEMENT
As discussed above, we will study about what do we mean by good governance, why
it is essential to have good domestic governance, the importance of partnership for
good governance and good management principles.
Let us begin with what is governance? The act or process of exercising authority
or power over political units is known as governance. We should not merely have
governance, we need to have good governance. Why is it so? This is because good
governance in partnerships with developing country governments, non-governmental
organizations and labour unions is essential for sustainable improvements in the nutrition
and health programmes. Good governance is the foundation of sustainable development.
This requires developing transparent democratic institutions, independent and fair
judiciaries, and strengthened law enforcement that can combat corruption. When
development programmes are infused with democratic principles and approaches, a
cycle of benefits accrues. The programmes not only achieve better results but also can
change the way communities go about solving problems. In addition, we also need
good domestic governance. Good domestic governance is essential because almost
every aspect of sustainable development is affected by the quality of civil society,
political participation, decision making, and responsible and reliable governance.
Since, good governance is the fundamental requirement for progress and sustainability,
furthering it is the strategy to foster sustainable development. There are certain goals
that support good governance. These are:
l democratic institutions that are effective, accountable, and transparent,
l an independent and fair judiciary,
l law enforcement that - with integrity - protects the people while strengthening
their capacity to combat corruption, 343
Public Nutrition l sound monetary; fiscal, and trade policies that promote economic growth, social
development, and environmental protection, and
l participation by all members of civil society in decisions that affect them.
Democratic governance supports sustainable development by making institutions and
policy making more accountable, transparent, and responsive. Free and fair elections
allow people to select and change their leaders and to express their preferences for
political parties and popular movements. Increasing political participation allows citizens
to influence the allocation of health services, food, clean water and sanitation. A
vibrant and politically active civil society, with a free press and the right to free
association, will hold institutions accountable, more so when policy making is transparent
and responsive to the concerns of citizens.
An independent and fair judiciary is also crucial for good governance. Solid judiciaries
support laws that protect people, commerce, and the environment, and they enable
enforceable contracts - a cornerstone of a functioning economy. Good governance
also facilitates economic growth and equity. Both are shackled by corruption, a
worldwide problem that distorts investment decisions, leads to misallocation of resources,
and has a disproportionate impact on the poor.
Governance issues are critical at local levels, where participatory problem solving
permits effective resource allocations. For example, a population and child nutrition
programme in Morocco promotes localized management of public health services in
order to reduce bureaucracy and permit more direct assistance. This assistance will
be more efficiently targeted through collaboration between public health officials, non
governmental organizations, community associations, and the private sector. Similarly,
in India local self government like panchayat raj institutions plays a significant role in
sustainable improvements in nutrition and health status of the communities. This takes
us to the importance of partnership for promotion of good domestic governance. Let
us review this in detail.
Importance of partnerships for good domestic governance

Good domestic governance can be promoted through a wide range of partnerships.
Significant partnerships of government programmes with local NGOs, community
based organizations, civil society and democratic processes. Similarly, addressing
employment and labour issues is essential to poverty alleviation and sustainable
development, and that labour unions often play key roles in promoting civil society,
fostering political participation, and demanding accountability from elected leaders.
The abilities of developing countries to design and institutionalize the social safety net
policies and programmes needed to foster economic growth and workers protection.
We know that public nutrition requires multisectoral approach to solve nutrition problems
so it becomes essential that public nutrition programmes are managed by multidisciplinary
teams. Let us see the principles we need to follow for managing successful nutrition
programmes.
Good Management Principles: The Value of an Integrated Approach

An integrated, cross-sectoral approach is required for addressing governance and
sustainable development in public nutrition programmes. Good management involves
multisectoral teams from various sectors to manage the programmes. For example,
sustainable improvements in nutritional status in communities are possible only when
agriculture and nutrition sectors work together. This could be further enhanced by the
participation of irrigation departments and community members and organizing and
training small community groups etc.
A good and effective programme management requires a good nutrition/

health programme team along with a good leader to guide.
344
Thus, for a good programme management, a multi-disciplinary team is required, who Programme
is able to: Management and
Administration
l understand the people (realizing their problems, communication with the people),
l elicit community participation,
l work efficiently with maximum use of available resources, and
l institutionalize overall efficient administration, no waste of resources, proper co-
ordination among the team.
Thus we saw that good governance and good management are required for successful
public nutrition programmes. Good governance is required for sustainable improvements
in nutrition and health status of people.
1. What is the importance of good governance and what are the goals that support
good governance?
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2. Describe briefly the principles of good programme management.
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14.7 LET US SUM UP

In this unit, we began our study by understanding the concept of programme
management and administration. Programme management is defined as getting people
to work harmoniously together to make efficient use of resources to achieve the
objectives. Since programme management involves working with people, especially
skilled and competent people we discussed in detail about personnel management
which has a special role to identify, recruit, train and maintain the staff responsible
for nutrition programmes. We discussed the roles, skills of a personnel manager
and the core functions he/she is expected to perform in an organization. We studied
about various steps involved in process of planning, implementing and evaluating a
public nutrition programme. While doing so, we reviewed various questions that need
to be answered while designing a programme. We also described in detail the
process of needs assessment/situational analysis since this is the first step to design
a programme. We learnt about the most commonly employed methods/techniques for
conducting needs assessment. We discussed each method’s purpose, procedures,
advantages and disadvantages, which will serve as a guide in the selection of an
appropriate technique for the collection of first-hand information on local needs for
the community. We concluded that for a programme to sustain it is important to
have good governance and good management principles. Thus, we ended our discussion
by learning about the issues of governance and principles of good management
principles. 345
Public Nutrition
14.8 GLOSSARY
Civil society : includes voluntary and non-profit organizations of many
different kinds, philanthropic institutions, social and political
movements, other forms of social participation and
engagement and the values and cultural patterns associated
with them.
Key stake holders : people who have an interest or are affected by a an activity.
Normative : relating to, or prescribing a norm or standard.
Political unit : a unit with political responsibilities.
Remuneration : wages or salaries including retroactive wages or salaries

Bonuses including stock bonus plans; Extra pay for overtime
work pay for holidays, vacations or periods of sickness.

EXERCISES
1. Programme management can be defined as getting people to work harmoniously

together to make efficient use of resources to achieve the objectives. A public
nutrition team has three main functions of management. These are planning,
implementation and evaluation of public nutrition programme. Administration, on
the other hand, is a wider term and encompasses such activities as spelling out
policies and objectives, establishing suitable organization structures and providing
necessary resources for realization of objectives.
2. The Management functions include planning, organizing, directing and controlling.

While Operative functions include procurement, development, compensation and
integration.
3. The knowledge and skills required by the personnel manager include a broad
background in the fields of psychology, sociology, philosophy, economics and
management, he or she must deal with situations which often do not have right
answers for all, an ability to understand not so logical demands of the employer
or employee, a capacity to programme oneself into others position without loosing
perspective, and skills in predicting human and organizational behaviour.

1. Steps in designing a nutrition health programme are:
l Identify the issues or health problems in the community,
l Prioritize the issues or nutrition health problems, to identify the one that the
programme will address,
l Identify risk factors and set the goal for the programme,
l Determine contributing factors and state objectives for the programme,
l Determine what the strategies will be,
l Develop the action plan for the programme and implementing them,
l Sustain the programme or keep the programme (or some parts of it) going,
346 l Evaluate the programme
2. Sustainability means thinking of ways to keep the programme (or important parts Programme
of it) going after its official end. Points to consider when planning for sustainability Management and
Administration
include how will the programme team assess the ongoing need for the programme?
are community members involved in the management of the programme?, what
skills and facilities are required by the community to manage and maintain the
programme?, is training needed? Is it available? How will the community access
it?, who can continue the work etc.
3. Steps in the process of evaluation are :

i) Focus of evaluation v) Collection of data
ii) Formulation of questions for evaluation: vi) Analyze data
iii) Designing strategy for evaluation: vii) Reporting
iv) Coordinate plan for evaluation viii) Reassessment
1. Situational analysis/needs assessment describes a process by which the assessment
of the current situation in the community is undertaken, value-based judgements
regarding the preferred or desired situation are reached, and some determination
of the priority status of local needs is made.
2. Techniques commonly used for conducting situational analysis are:
a. Key informant approach: collect information from those community members
who, because of their professional training and/or affiliation with particular
organizations, are in a prime position to obtain a more comprehensive viewpoint
of what the needs facing the community are.
b. Public forum approach: elicit information from a wide range of community
members concerning issues and community needs via group discussion taking
place at a series of public meetings in the community.
c. Nominal group process technique: strategy to gather individual’s ideas in
face-to-face non-threatening situations.
d. Delphi technique: an idea-generating strategy that is more structured than
the nominal group process and uses a series of questionnaires and summarized
feedback reports from preceding responses.
e. Survey approach: collect information from a wide range of community
members concerning issues and community needs via their responses to
specific questions.
3. Advantages of nominal group exercises are:
l If well organized in advance, a heterogeneous group can move toward
definite conclusions.
l Can be used to expand the data obtained from surveys or existing documents,
or can be used to generate a more specific survey.
l Motivates all participants to get involved because they sense they are
personally affected.
l Generates many ideas in a short period of time, allows for a full range of
individuals’ thoughts and concerns.
l A good way to obtain input from people of different backgrounds and
experiences
347
Public Nutrition 4. Disadvantages of conducting a survey
l This approach is often the most costly.
l To ensure statistical meaning, samples must be carefully selected.
l Results may not be valid if survey is not designed correctly.
l May require time and expertise to develop the survey, train interviewers,
conduct interviews, and analyze results.
l Is subject to misinterpretation depending on how the questions and response
categories are designed.
1. Good governance in partnerships with developing country governments, non-
governmental organizations and labour unions for sustainable improvements in the
nutrition and health programmes. The goals that support good governance are:
democratic institutions that are effective, accountable, and transparent, an
independent and fair judiciary law enforcement that with integrity - protects the
people while strengthening their capacity to combat corruption, and environmental
protection and participation by all members of civil society in decisions that
affect them etc.
2. The principles of a good programme management are implementation of the
programme by a multi-disciplinary team, who is able to understand the people
(realizing their problems, communication with the people), elicit community
participation work efficiently with maximum use of available resources, and
institutionalize overall efficient administration, no waste of resources and proper
co-ordination among the team.
348
Conceptualization
UNIT 15 CONCEPTUALIZATION AND THE and the Process of
Nutrition Education
PROCESS OF NUTRITION
EDUCATION
Structure
15.1 Introduction
15.2 Understanding the Need and Scope of Nutrition Education
15.3 Importance of Nutrition Education
15.4 Potential Challenges and the Constraints of Nutrition Education
15.5 Theories of Nutrition Education
15.5.1 Cognitive – Gestaltist Theory
15.5.2 Behaviourist Theory
15.5.3 The Communication Approach Theory
15.5.4 Diffusion - The Special Type of Communication
15.5.5 The Social Marketing Approach Theory
15.6 Process of Nutrition Education Communication

15.7 The Conceptual Phase
15.7.1 Identify Nutrition Problems and the Population at Risk
15.7.2 Analyze the Causes of the Problems
15.7.3 Formative Research
15.7.4 Defining the Behaviour
15.8 Let Us Sum Up

15.9 Glossary
15.1 INTRODUCTION
In this unit and the next three Units 16, 17 and 18, we will study about the concept,
scope, need importance and process of nutrition education. You might be having
various questions related to nutrition education in your mind, like what is nutrition
education? How well or poorly does nutrition education work? Does it deal better
with some nutritional problems compared to others? You can probably get the answers
to some of these questions as you read through these units.
In this unit, we will learn about the basic concepts related to nutrition education. We
will learn about the potential challenges and constraints of nutrition education and
various theories of nutrition education. The process of nutrition education consists of
four phases. These are: conceptualization, formulation, implementation and evaluation.
In this unit, we will study in detail about conceptualization and briefly introduce you
to the other three phases.
Objectives
l describe the need and scope of nutrition education,
l discuss the importance of nutrition education,
349
Public Nutrition l enumerate the challenges and the constraints of nutrition education,
l describe the various theories of nutrition education, and
l explain the overall process of nutrition education.
15.2 UNDERSTANDING THE NEED AND SCOPE OF

NUTRITION EDUCATION
We will start this section by learning about the history of nutrition education and by
exploring how the need for nutrition education evolved over time. We will then
discuss some definitions of nutrition education and explain the scope. So let us begin
our study on the topic by looking at the history of nutrition education.
The beginning of modern nutrition education may be traced to the early attempts to
prevent protein energy malnutrition (PEM) in infants and children, primarily due to
faulty weaning. The need for nutrition education evolved about half a century ago,
when in 1950, the first report of the Joint Food and Agriculture Organization/ World
Health Organization (FAO/WHO Expert Committee on Nutrition), recognized the
need for nutrition education in developing countries. This report brought this need to
international attention and emphasized the importance of nutrition education in the
health sector. By 1958, the same committee reported, “Education in nutrition is a
necessary part of practical programmes to improve human nutrition…” and
recommended the channels for nutrition education such as schools, maternal child
health (MCH) centers, community development and related programmes. We can
thus see that, nutrition education, as an interventionx came into prominence with the
realization that malnutrition to a large extent is not only due to inadequate food
availability but also due to faulty food habits, some of them based on food prejudices,
superstitions or taboos, and importantly, lack of awareness of the right food choices.
Therefore, nutrition education was accepted as an important measure for the promotion
of nutrition and well being, and was placed at a level of priority equal to that of
other interventions.
So then what is nutrition education? Nutrition education has been viewed as the
process of persuading people to act in their own best interest for attaining
nutritional well being. It has long been established in an informal unstructured way,
often being embedded in traditional folklore.
Let us get to know more about this process by looking at some important definitions
of nutrition education, as proposed by some experts.
“According to WHO, the focus of health and nutrition education is on people and
action. In general, its aims are to persuade people to adopt and sustain improved/
desirable nutrition and health practices and to take their own decisions, both individually
and collectively to improve their nutritional and health status, and environment.”
“Nutrition education can be defined as any set of learning experiences designed to
facilitate the voluntary adoption of eating and other nutrition-related behaviour
conductive to health and well being.
“Nutrition education is the process of applying a knowledge of nutrition related
scientific information and social and behavioural sciences in ways designed to influence
individuals and groups to eat the kinds and amounts of foods that will make a
maximum contribution to health and social satisfaction.”
“Nutrition education may be defined as a group of communication activities aimed
to bring about a voluntary change in practices, which have an effect on nutritional
status of a population. The ultimate goal of nutrition education is to improve nutritional
status.”
350
“The term “nutrition education” applies to any communication system that teaches Conceptualization
people to make better use of available food resources with the ultimate goal of and the Process of
Nutrition Education
improving nutritional status.”
So, you can note that there are many definitions of nutrition education. Having gone
through these definitions, in your opinion, what is the basic concept highlighted in
these definitions. Yes, the concept highlighted is that nutrition education essentially
involves communication for behaviour change. As a worker in public nutrition,
you will come across terms like Communication for Behaviour Change (CBC) and
Information, Education, Communication (IEC) or Nutrition Education (NE). What are
these terms? Are these interchangeable? Let us see first how they are defined.
“Communication for Behaviour Change (CBC) is a multi-level tool for promoting and
sustaining risk-reducing behaviour change in individuals and communities by distributing
tailored health messages in a variety of communication channels”.
“Information, Education, Communication (IEC) combines strategies, approaches and
methods that enable individuals, families, groups, organizations and communities to
play active roles in achieving, protecting and sustaining their own health. Objectives
of IEC are to identify and promote desirable behaviours”.
We can note that CBC, IEC and nutrition education are, in fact, interchangeable,
since they all aim at creating awareness, motivating people to change behaviours
and result in necessary action.
Sometimes it is customary to use the term Nutrition Education communication (NEC)
in place of nutrition education. You have read in the Unit 1, Section 1.5 that nutrition
is a determinant of health status, therefore, nutrition education communication falls
under the broad area of health communication. Let us then try to understand what
is health communication? “Health communication can be broadly defined as the
systematic attempt to influence positively health practices, using principles,
instructional design, social marketing, behaviour analysis, and medical
anthropology.” The primary goal of health communication is to facilitate change in
health-related practices and, in turn, health status.
You should know here that Nutrition Education Communication (NEC) strategy is
within the reach of most programmes. It can teach people beneficial facts about
nutrition and food, can help them develop necessary skills, and can communicate in
a manner that motivates them to make life style changes on a sustained basis. So,
we can conclude here that nutrition education involves a set of communication
activities and falls under the umbrella of health communication. Let us study about
the role and importance of nutrition education in some more detail in the next
section.
15.3 IMPORTANCE OF NUTRITION EDUCATION

Now, that we know what nutrition education is, can you visualize the importance of
this important activity. Yes, nutrition education can play a vital role in improving
nutritional status of all the individuals within a family or community, if they adopt
positive nutrition behaviours. Nutrition education also has a vital role to play for
policy makers as it helps mainstreaming nutrition into various projects and programmes.
The following points tell us why nutrition education is important and essential:
1) Nutrition education reinforces knowledge and corrects faulty concepts about
nutrition.
2) It allows the individual to evaluate the nutrition information he or she receives.
3) It promotes the best use of an individual’s limited economic resources.
351
Public Nutrition 4) It promotes the concept of “health’ as a valued community asset.
5) Nutrition education equips the individuals with the ability to make judicious food
choices for health and well being. Nutritionally aware parents can pass on
appropriate eating habits to their children. If importance of good nutrition is
ignored, undesirable eating patterns may develop from early childhood causing
eating problems leading to malnutrition (both under nutrition and overweight /
obesity). Thus, members with different physiological needs in a family can
benefit from nutrition education as follows:
l If families learn the importance of child nutrition, they can promote optimal
development of their children. Mental development is almost complete by
the second year of life and nutrition is crucial for brain development.
l School children and adolescents, who are nutritionally aware of healthy
foods, can adopt practices, which will help them in normal growth and
development and will enable them to avail of maximum benefits from
education.
l Adolescent girls by understanding the importance of nutrition and healthy
food choices facilitate their own optimal growth during adolescence and
ensure safe motherhood in future.
l Pregnant women, by making the right food choices, increase their chances
of a healthy pregnancy and a normal birth weight newborn.
The following points summarize why nutrition education is important for policy makers
and programme planners.
1) Nutrition education is vital for policy makers and programme planners, simply,
because they should be educated about extent, magnitude and distribution of
various nutritional problems in the country. They should also be educated about
causes and consequences of these problems. Nutritionists have the essential
role of advocating and impressing on the government officials about the need
for a good food and nutrition policy to be included in the economic planning.
2) Nutrition education helps policy makers and programme planners in formulating
policies for other sectors like agriculture, rural development and education etc..
Since, causes of malnutrition are at multi sectoral level, contribution of other
sectors to improved nutrition can very well be recognized if the policy makers
themselves are educated about nutrition.
3) Commonly nutrition education acts as a conserving force maintaining the validity
of the culture and as an innovative force facilitating adjustment to contemporary
problems and conditions. In general public, there is a tremendous gap between
current nutrition knowledge and the dissemination and application of such
knowledge. People do not instinctively choose what is best for them and so
nutrition education becomes an essential activity. Initially the community may
resist attempts at change and it would be useful to pay attention to what they
see as their priority areas.
Thus, it must be clear that nutrition education to population groups and policy makers
has a potential to improved nutritional status. Now the next question, which comes
to our mind is, whether nutrition education can really contribute to, improved nutritional
status or not? Nutrition education has been a part of various programmes for many
years. If this is so, then we would have seen remarkable changes in the nutrition
situation of the people. However, this issue is not as simple as it sounds. Let us find
out more about this complex issue in the coming section.
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Conceptualization
15.4 POTENTIAL CHALLENGES AND and the Process of
Nutrition Education
CONSTRAINTS OF NUTRITION EDUCATION
We face a big challenge when we plan to change behaviours of people through
nutrition education. Also “how much of an improvement in nutritional status can be
expected to be achieved through nutrition education?” is a frequently asked question.
Nutrition education is considered unique and at the same time difficult because
improved nutrition requires sustained and repeated individual behaviour. There are
other reasons why nutrition education is challenging. The reason why people eat
what they eat is complex and it involves both cultural and psychological aspects.
Changes in food consumption patterns require shifts in deeply ingrained food habits
established since childhood.
Further, in very poor communities nutrition education cannot be effective without
simultaneous increase in real income. Nutrition education teaches better use of
resources, which are already available to the family. When these resources fall
below a certain level, redistributing them does not help, as this would not meet the
actual requirements. Therefore, it is not surprising that nutrition education for
nutritional status improvement in food insecure communities is often viewed with
skepticism because malnutrition is largely believed to be a reflection of poverty.
However, there is also a view that, NEC does have the potential to make a
difference even in communities having poor resources. Thus, at a given level of
income, NEC can:
l favourably influence practices like food purchase, preparation and storage and
a more equitable intra-household food distribution, which meets the need of
both male and female members,
l inform families on how to add important nutrients like micronutrient and rich
foods through dietary diversification, particularly for vulnerable groups like infants;
l counter harmful traditional beliefs and practices related to dietary intake of
women and infants.
You will learn more about nutrition education communication in later sections. Here
we would like to emphasize that NEC, if designed, implemented and evaluated
properly by committed personnel, there indeed are positive and significant impacts
seen on nutrition behaviour and nutritional status of vulnerable groups, even in
resource deprived communities.
The documented literature indicates that NEC does lead to behaviour change. One
area where success in behaviour change has been achieved is in the projects on
“Breast feeding and complementary feeding practices”. This is mainly because
behaviours related to breast feeding and complementary feeding are influenced more
by cultural beliefs and traditions than resources.
In fact nutrition educators have come up with various theories to understand how
and why people change their behaviour. This brings us to the next section, i.e.
theories in nutrition education. We will now look at some theories of nutrition
education.
15.5 THEORIES OF NUTRITION EDUCATION

Nutrition educators have become increasingly aware of the importance of
understanding the audience they want to influence. The field of communication
offers nutrition educators practical theories for understanding people, their knowledge,
attitudes and behaviour regarding nutrition. We will discuss here five main theories
of NEC. These theories are: cognitive – gestaltist theory, behaviourist theory, the
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Public Nutrition communication approach theory, diffusion and the social marketing approach theory.
We will discuss each of these theories in detail. Let us start with cognitive –
gestaltist theory.
15.5.1 Cognitive – Gestaltist Theory

According to the cognitive-gestaltist theory, education is seen as a process of self-
development, whereby, the individual takes control of his/her environment. When this
theory is used as a basis for nutrition education, it assumes that individuals are
basically rational, they are able to make free choices and when provided with
relevant information, they will adopt behaviours that are healthy and self-actualizing.
Therefore, the goal is to disseminate relevant information.
Let us go over to the next theory i.e. behaviourist theory
15.5.2 Behaviourist Theory

Behaviourist theory is based on the premise that the inner cognitive experience is not
the only determinant of behaviour. Behaviour is considered determined by the
environment, which may consist of competing forces to provoke and reinforce unhealthy
behaviours. It is argued that people are not free to make decisions as long as these
environmental stimuli continue to be there. It is assumed that sufficiently strong
stimuli and reinforcement will have to be set up for the learners. In all practical
interventions, elements from both theories are used.
Let us next go to the communication approach theory.
15.5.3 The Communication Approach Theory

The communication approach theory states that the receiver is selective in his response
to the communication, the factors responsible for this selectivity being the individual’s
psychological orientation. This is known as the “communication effects” perspective.
According to this theory, different people react differently to the same message.
In addition, each individual also has a stored experience of beliefs and values. These
beliefs and values influence the way the receiver interprets the message. This ‘individual
differences’ perspective postulates that people with similar beliefs and values will
respond similarly to a given message and in a predictable manner. Further it is also
seen that people of the same age and sex and who have same level of education
and wealth tend to select communication content of a similar nature and respond to
it in a similar fashion. This is called the ‘social categories’ perspective. Both the
individual differences perspective and the social categories perspective are considered
important in their ability to predict response of the audience to communication.
These theoretical perspectives have led to some conclusions:
l Communication through the interpersonal channel is considered more influential
than mass media in effecting behaviour change.
l Individual factors such as educational level and social categories influence
responses.
l If change occurs, it is likely to be in small increments and in the direction of
previous inclinations.
l Changes occur only after a lot of effort.
It is very important that while formulating communication material and in interpreting
the response to communication, both individual differences and social factors are
considered.
354 Let us learn about diffusion theory next.

15.5.4 Diffusion – The Special Type of Communication Conceptualization
and the Process of
Diffusion is described as a special type of communication, whereby, innovations Nutrition Education
spread to the members of a social system. While the term communication encompasses
all messages, the term diffusion is concerned with messages that are new to the
audience that receives it. In a free choice situation, diffusion of innovations occurs
more effectively when the sender and the receiver are alike in personal and social
characteristics.
The key elements of diffusion process are:
-- full diffusion of most major innovations requires considerable time.
-- innovations are more rapidly accepted if they offer advantage over existing
practices, are compatible with other current practices, are easy to understand
and use, and if their benefits are quickly and clearly demonstrable.
You would have experienced that it is not easy to accept new ideas. It is true with
most individuals. How do people go through a series of steps in accepting a new
idea? What are these steps? Let us review them one by one.
l Awareness – this is the first stage in the adoption process, when people will
know about an idea or product and become aware or conscious of it.
l Interest – once they know, it may arouse their interest or curiosity: what is it?
How does it work? How could it work for me?
l Evaluation – with more information about the idea, the person compares the
new idea with the existing one and might ask: how can I use it? Is it more
effective than what I am doing now?
l Trial – people by nature are active and want to get involved and try something
new. Hence they try the new concept.
l Adoption – the final stage is complete acceptance and use of the idea or
product.
Adoption-diffusion research shows that although individuals may be persuaded to
change, they are usually resistant to change and change occurs only slowly.
Lastly, let us learn about social marketing approach theory.
15.5.5 The Social Marketing Approach Theory

Social marketing of nutrition health concepts and practices has developed over the
past few decades. It is defined as a process or strategy to make people aware of
the goods and services available to them and how to make use of these. It is
believed that social marketing, like consumer marketing, should be responsive to
consumer needs, preferences and priorities. The similarities between social marketing
and consumer marketing should not however distract us from some of the important
dissimilarities between the two. Thus, dissimilarities between consumer marketing
and social marketing are:
l Consumer marketing (CM) promotes the sale of goods or services for a profit
while social marketing (SM) has the objective to promote welfare of the
people.
l CM tries to sell brands or products while SM tries to sell concepts and practices.
l The major concern of SM is with the poorer segments of the population,
although this might not always be so.
l While CM is concerned mostly about user, SM has to worry about the influences
of providers as well.
355
Public Nutrition The major contribution of the SM perspective appears to be the development of the
resistance resolution model for designing the message. This model postulates that a
message is divided into a number of elements. The audience receives successive
elements and reacts to them. If each element of the message is understood and
accepted by the audience, then each successive element reinforces the foregoing
element so that at the end of the message, the audience is persuaded to accept the
message and practice it. Frequency of exposure is an important factor and it is
admitted that several exposures are needed before the message leads to the adoption
of the desired behaviour.
You should, however, remember that, if any of the elements in a message is not
understood or accepted due to reasons of traditional beliefs or customs, it triggers
off conflict and distracts the audience. Such a distraction is referred to as internal
dialogue/dissonance. Successive elements may produce more internal dialogue until
eventually the audience may cease to listen at all and reject the whole idea. The
message design strategy of SM attempts to eliminate the internal dialogue by uncovering
resistance points and designing strategies to overcome them.
It is important to note that the process of interaction between the communicator and
the receiver (audience) can deal with dissonance in the course of interpersonal
communication. However, in the case of mass media, this is not possible and therefore
message design to overcome resistance is a very important consideration while using
the mass media.
We studied about various theories of nutrition education. Before we move on to the
next section, let us recapitulate what we have learnt so far, by answering the
questions given in check your progress exercise 1
1. “Nutrition education aims to change behaviour”. Justify the statement giving
appropriate examples.
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2. What are the potential challenges and constraints of nutrition education?
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3. Enumerate various theories of nutrition education.
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4. Read the following statements carefully and indicate if true or false. Correct
a. Social categories perspective states that similar people react differently
to the same message.
b. Diffusion is described as an act of transmitting new ideas or innovations.
c. Social marketing is same as consumer marketing.
356
Conceptualization
d. Communication through the interpersonal channel is considered more and the Process of
influential than mass media in affecting behaviour change. Nutrition Education
e. Nutrition education if designed, implemented and evaluated properly by

committed personnel can have positive effects on the behaviour of people.
We have studied so for what nutrition education is all about. We also learnt about
the scope and importance of nutrition education. We will now study about how we
plan and conduct a nutrition education programme i.e. the process of nutrition
education programme.
15.6 PROCESS OF NUTRITION EDUCATION

COMMUNICATION
You must be curious to know as to how do we go about actually conducting a
nutrition education programme? Well, there are many steps involved in the process
of conducting a nutrition education programme. During this process, we have to
identify the problem and analyze the causes of the problem. We should also know
what message to give and methodology to use to communicate to the people so that
they are able to improve their nutrition and health behaviours. We will now introduce
you to the process of nutrition education. You may recall that in the beginning of
this unit we learnt that nutrition education involves many communication activities.
So, before we discuss the process of nutrition education communication, let us first
understand what we mean by communication. Communication simply defined, is the
act of transmitting information, ideas and attitudes from one person to another
such that intended goals are met. There are four basic components of the
communication process. These are sender or communicator, message, receiver
and the feedback. Figure 15.1 illustrates the communication process.
Figure 15.1: Components of communication process

You can note from Figure 15.1 that the communication process is simple. The
sender or the communicator wants to communicate something and decides to
speak, write, send nonverbal or visual signals known as message. The receiver
wants to understand the sender’s meaning and therefore listens, reads or observes
non-verbal information or visual information and sends verbal or non-verbal feedback
to the sender.
Let us learn about each of these components in detail.
l The sender or communicator (source): People are exposed to communications
from many different sources and more likely to believe a communication from
a source they trust, that is, has high credibility. The reason why the same
individual responds differently to different communications also resides in sender-
controlled characteristics of communication i.e. the communicator’s attributes. 357
Public Nutrition l The message: The message consists of what is actually communicated including
the appeals, words, pictures and sounds that we use to get our ideas across,
for motivation or practice change. A well designed message addresses itself
clearly to the problem to be dealt with. It recommends a solution or action after
taking into account the resistance points to the desired action and has a
motivational element.
The presence of a channel is very important for delivery of message. This is also
sometimes referred to as the communication method. It is same as the medium,
which is the delivery system or channel of communication for a message. This
medium can be a person and/or an audio visual aid like radio or a television.
l The receiver (audience): The first step in planning any communication is to
consider the intended audience. A method that will be effective with one audience
may not succeed with another. Different individuals respond differently to the
same message, with the significant causes being present in attributes of the
receivers themselves.
l The feedback: Feedback is defined as the response or information provided
as a result of an event, the event in this case being the transmission of
information. Feedback occurs when the receiver receives the message from a
source through a medium/channel. The receiver listens, reads, or observes non-
verbal signals or visual information and sends verbal or non-verbal feedback to
the communicator/source who can modify the messages to make it more
persuasive to the receiver.
Thus, communication is effective if all these elements are present.
We can now look at the process of nutrition education communication. Nutrition
education communication involves a carefully planned and thought out process to
achieve the objectives of improved health and nutritional behaviours in the vulnerable
population. The scheme for planning a nutrition education is based on a theoretical
framework and consists of four phases namely: Conceptualization, Formulation,
Implementation and Evaluation as illustrated in Figure 15.2.
PHASE- 1: CONCEPTUALIZATION
Defining the nutritional problems
Determining the causes of the problems
Conducting formative research
PHASE-2: FORMULATION
Setting objectives
Designing messages
Choosing the media and multi-
media combination
PHASE-3: IMPLEMENTATION
Producing the materials
Training the change agents
Executing the communication
intervention
PHASE-4: EVALUATION
Figure 15.2: Process of nutrition education - phases

358
You can see in Figure 15.2 that each of these phases has different elements, for Conceptualization
example, conceptualization phase consists of identifying nutrition problems, analyzing and the Process of
Nutrition Education
the causes of the problems and conducting formative research. All the elements in
each of the 4 phases contribute in a specific manner to the final outcome of the
educational intervention. We will briefly review these phases here and then enumerate
key elements involved in the intervention design for behaviour change. Let us begin
with conceptualization phase:
A. Conceptualization phase
The first phase in designing / planning a nutrition education programme is
conceptualization. In the conceptualization phase, we determine the type and extent
of nutritional problems, identify the population groups at risk and analyze the causes
of nutritional problems. It is very important to analyze the causes of the problems
as it helps to identify the factors which influence these problems. Therefore, problem
analysis is the first step in conceptualization. Problem analysis is conducted by a
method called causal analysis. This method has proven very useful in nutritional
diagnosis. It involves drawing up a network of factors known or presumed to affect
nutritional status in a given context. Since, there can be several factors which can
contribute to nutritional problems, we would like to understand the factors specific
to the community for which interventions are designed. We will learn in greater
details about causal analysis later in sub-section 15.7.2. For conducting causal
analysis specific to a community, we conduct formative research. Formative research
is, in fact a term which describes investigations conducted for programme
design and planning. Formative research helps us to understand the context, need
and characteristics of a community before we plan a nutrition education communication
programme. It helps to understand specific human actions and behaviours and the
cultural, social, economic, environmental and political factors that influence these
human actions and food behaviours as highlighted in Figure 15.3.
Figure 15.3: Factors influencing food behaviours
You can note from Figure 15.3 that food behaviours are affected by environmental
factors such as social, physical, economic and informational environment and
interpersonal factors. They are also influenced by experiences which an individual
might have had with the food and some biological factors. The findings of formative
research show the undesirable behaviours and factors affecting these behaviours.
359
Public Nutrition We can thus identify behaviours which should be adopted by the target group and
the actions which must be taken in order to modify the behaviours in question.
Once the programme has been conceptualized, we move on to the formulation

phase.
B. Formulation phase
In the formulation phase, we give shape and structure to the elements we
conceptualized in the conceptualization phase. The first step in formulation phase is
to define the clear objectives for the NEC programme. These objectives should be
specific, measurable and time bound. We also identify the audience who will be
targeted for behaviour change. For example, we may identify the mothers of children
below the age of 6 years, especially children below 2 years and pregnant and
lactating mothers for nutrition education.
We discussed above that from findings of the formative research, we determine the
current behaviours and the factors affecting these behaviours. This process facilitates
the development of messages. So, we develop messages during formulation phase.
Again the findings of the formative research can identify the popular channels of
communication or media in the community. We develop a choice of media mix in
order to develop optimum synergy between the channels. After we identify the
media mix, we can decide on the support materials to be developed for the programme.
Support materials are those on which messages are transmitted for example, posters,
radio programme. The next step in the formulation phase is to formulate a
communication strategy in which all the communication activities as discussed in the
previous are integrated with each other. We will discuss the formulation phase in
detail in Unit 16.
We will now briefly discuss the implementation phase.
C. Implementation phase
Implementation means carrying out the activities in the field. You are familiar with
the term “implementation” as you read about implementation of public nutrition
programme in Unit 14. Implementation of NEC programme basically includes being
ready with the software (the people or the nutrition educators) and the hardware
(the messages, material and communication strategies). Implementation phase has
three aspects. production of support materials, training and executing the
communication intervention. In the formulation phase we identified messages and
media mix and decided on the support materials. Thus, during the implementation
phase we produce the support materials. You should realize that support materials
should always be used, whatever the scope of the project, as they serve to reinforce
person-to-person communication. You should also know that prior to implementation,
the nutrition educators should be trained appropriately in all aspects of NEC, particularly
counselling and communication methods, monitoring and evaluation of the programme
and learning from the experiences. We need to ensure that all persons involved in
various communication activities carry out adequately their roles in their respective
sectors. We involve a multidisciplinary team in training for the NEC programme.
They should very well understand and know the messages content as well as the
technique to effectively communicate these messages. There are different methods
of communication which can be used to disseminate messages to the community. It
is also important during implementation that the health system and health nutrition
services are geared to meet the increased expectations and demands for quality
services from audiences who have been exposed to NEC. We will cover
implementation of NEC in detail in Unit 17 later in this course.
After we have implemented activities in the field, we would like to assess how we
are doing. For this we conduct evaluation. Let us study this last phase briefly.
360
D. Evaluation phase Conceptualization
and the Process of
Evaluation is the measurement and assessment of the success of a communication Nutrition Education
programme in reaching its goals. Evaluation must be considered as a necessary
support activity, an instrument for refining or restructuring communication activities.
We should try to make evaluation a participatory process, which will involve the
educators, service providers, planners and the community. The evaluation must
respond to two fundamental questions. These are: 1) Have the objectives been met?
2) Has the implementation process satisfied the various persons involved in the
intervention and above all the population concerned. You are already familiar with
the evaluation process as you read about the evaluation of public nutrition programme
in Unit 14. An evaluation plan would guide us about what, how, where and when
we will evaluate the nutrition education programme. While nutrition education activity
is common, the assessment of nutrition education, especially the whole process is
not. The great majority of nutrition education programmes are not evaluated and
apparently assumed to be ineffective. Therefore, it is very important to evaluate any
nutrition education programme.
Having gone through the discussion above, it must be clear that the process of
nutrition education includes conceptualization, formulation, implementation and
evaluation. Figure 15.4 summarizes the key elements discussed above in the
intervention design for behaviour change.
A. Identifying B. Analyzing causes C. Conducting Formative

nutrition for nutrition research and determining
problems problems factors affecting nutrition
behaviours
F. Identifying E. Developing D. Setting objectives

channels for messages and identifying
transmitting message target audience
G. Implementation in H. Evaluation of
the community the process
Figure 15.4: Key elements in the intervention design for behaviour change
Identifying the nutrition problems, analyzing causes of the problems, conducting

formative research to identify factors affecting the behaviours are all part of the
conceptualization phase. Setting objectives, message design and identifying channels
for transmitting messages fall under the formulation phase. The implementation
stage includes development and production of support materials, pretesting these
materials, training of educators and disseminating messages to the community
through various communication methods. In the evaluation phase, we develop an
evaluation plan which will guide us to assess if the objectives have been met and
if the implementation process satisfied the various persons involved in the intervention
and above all the population concerned. As discussed earlier, we will study about
conceptual phase in detail now. The subsequent units 16,17 and 18 will have detailed
discussions on formulation, implementation and evaluation phases. But before you
move on to the next section do answer the questions given in check your progress
exercise 2. 361
Public Nutrition
1. Enumerate the components of communication process.
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2. What are the four phases of the process of nutrition education?
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Now, let us study about the conceptual phase in greater details.
15.7 THE CONCEPTUAL PHASE

In this section, we will study about various elements involved in the conceptual
phase. The conceptualization phase, as highlighted in Figure 15.2, focuses on identifying
the type and extent of nutritional problems, identifying the population groups at risk
and analyzing the causes of nutritional problems. Let us study each of these elements
in greater details:
15.7.1 Identify the Nutrition Problems and the Population at Risk

The first step in conceptualization of NEC programme is to identify the type and
extent of nutrition problems and the population at risk. Nutrition educators generally
have to address nutritional problems of two types of population – the undernourished
who are susceptible to infections and, the well nourished who are susceptible to
degenerative diseases. The general consensus appears to be to tackle problems for
which affordable solutions exist and defer the others.
For identifying the nutritional problems, we can ask certain questions to ourselves, for
example:
What is this problem? How is it manifested?
What population is affected?
What is its impact on the social, economic and cultural life of the population concerned?
Is it a priority public health problem?
Finding answers to these questions would help us to conceptualize the issues related
to the problems prevalent in the community. We can identify the nature, extent and
the magnitude of the problem, groups affected, its socioeconomic importance and
prioritization by conducting nutritional assessment of the community. You might recall
that we learnt about assessment of nutritional status in earlier Unit 7 and 8. We also
learnt about different nutritional problems prevalent in our country. To recall the
principal nutritional problems in our country, these are protein energy malnutrition
(PEM), vitamin A deficiency disorders, anaemia and iodine deficiency disorders.
Suppose we conduct assessment of nutritional status in a community and we may
come up with many nutritional problems. For example, about 50% children 0-3
362 years of age in that community are low weight for age, only 20% children exclusively
breast fed for first six months of life, only 25% of 6-9 months old children, have Conceptualization
been introduced to complementary foods in addition to breast milk and so on. So, and the Process of
Nutrition Education
we can see that the nutritional problems can be many in a given situation. So what
do we do? We would be required to prioritize the problems to be addressed in
consultation with the community. The next step after we prioritize the problems is
analyzing the cause of each and every prioritized problem. Let us review this next.
15.7.2 Analyzing the Causes of the Problems

After we identify the problems and prioritize them, the next step is to analyze the
causes of the nutritional problems. We identify list of factors known or presumed to
contribute to the nutritional problems. This is known as causal analysis. It is known
that casual analysis is absolutely necessary for the successful design and implementation
of nutrition education programme. Why is it so? This is because nutritional problems
are the results of an interaction between complex and multiple socioeconomic, biological
and environmental factors. We can take one of the problems identified earlier and
conduct casual analysis. For example, 50% children 0-3 years of age in that community
are malnourished or low weight for age. What are the problems contributing to this
condition? We have already discussed about causes of malnutrition in Unit 2 and
Unit 3 earlier. Some of these are, as you know, poor infant and child feeding
practices, lack of awareness, low socioeconomic status, poor household food security,
low accessibility to health services and poor environmental conditions. You may
recall reading in Unit 2, Figure 2.1 about the conceptual framework portraying the
causal factors and their interaction, leading to malnutrition. These were at three
levels - immediate causes, underlying causes and basic causes. Further, according
to this framework, the immediate causes of poor nutritional status/malnutrition are
poor dietary intake and disease. You can note in Figure 15.5 that for casual analysis,
we have further analyzed the factors which contribute to poor food intake. Let us
take the cause - poor food intake and study the various factors contributing to
inadequate food intake.
Malnutrition

  
Immediate Underlying Basic
causes of malnutrition causes causes
 
Poor Food intake Disease
   
Child feeding Household food Intrahousehold food Interaction between mother

practices consumption distribution and child
  
Family food Food availability at Food taboos
habits household level
 
Household food Local food Supplemental
budget production food
Figure 15.5: Casual analysis for malnutrition
These are, for example poor child feeding practices, inadequate household food
consumption, intrahousehold distribution etc. We can take one of the factors such as 363
Public Nutrition inadequate household food consumption and further identify its cause such as family
food habits, taboos etc. Thus, we identify factors contributing to each cause at
successive levels. Like this we can construct a chain of causality with linkages
formed progressively and organized into a hierarchy. With the result we get a network
of factors affecting nutritional status. We then identify the factors which are linked
to human behaviours. Only these factors are most likely to be amenable to nutrition
education. For example, you may note from Figure 15.5 that the child may not be
consuming enough food because the mother has poor awareness about what all food
to give to the child. Mother may also have certain misconceptions about what to
feed the infant. These are the factors which are amenable to nutrition education
communication because mothers can gain knowledge about what to feed the baby
and remove the misconceptions about feeding through education. Like this we need
to take each and every problem identified during assessment of nutritional status,
conduct casual analysis and identify factors most likely to be changed through
educational approach. Eventually, we will get a list of behaviours linked to these
factors which can be addressed during the education programme.
In our discussion so far we have discussed about causal analysis and the different
factors known or presumed to be contributing to malnutrition. However, when we
actually plan to conduct a nutrition education communication programme, we need to
learn from the community about various factors which affect the nutrition and health
behaviours of the population. Once we understand the context of the community, we
can plan a programme which will meet the specific needs of the community. For
this we conduct a type of research known as formative research. Let us study about
formative research in detail, next:
15.7.3 Formative Research

As discussed earlier, formative research describes investigations conducted for
programme design and planning. It helps to understand the context, need and
characteristics of a community. Formative research is done on a representative
sample of a target audience to understand the cultural, social, economic and political
factors as highlighted in Figure 15.3, that influence human actions and behaviours.
Thus formative research helps to:
l understand motivators and barriers to optimal practices,
l create messages and materials specific to the needs of the community, and
l ensure messages and programmes are appropriate, acceptable and feasible to
beneficiaries.
The results of formative research aid the programme planners in establishing
measurable objectives and realistic strategies for the programme. Before conducting
formative research, you would realize that it will be useful to develop certain research
questions. These are as follows:
l What are the behaviours and how can we describe them?
l What influences human behaviour?
l What is the role of culture, social change and economic factors in determining
behaviours?
l How do we use an understanding of behaviour, and plan nutrition-health education
and nutrition-health promotion programmes?
Finding answers to these questions can help us to identify current behaviours (which
may or may not be optimum), factors affecting these behaviours and the barriers
which prevent adoption of optimum behaviors.
We can use certain methods in formative research to answer some of the questions
364 mentioned above. Let us now learn about these methods.
Method used in formative research Conceptualization
and the Process of
Formative research methods help us understand the cultural, social, economic and Nutrition Education
political factors that influence human actions and behaviours. We can use either a
single method or a combination of methods. Some of the commonly used methods
used in formative research are: focus group discussions, individual in-depth interviews,
participant observations, direct observation, informal conversions and ethnographic
studies. We will briefly review each of these methods now.
l Focus group interviews: The focus group interview method brings together
eight to ten respondents typical of the intended target audience. A trained
interviewer uses a prepared list of probing questions to collect information on
vocabulary, attitudes and concepts related to the selected nutrition problem.
Here, the group atmosphere may stimulate more in-depth discussion than individual
interviews do. The insights into the commonly held beliefs can also be obtained
relatively quickly.
l Individual in-depth interviews: The individual in-depth interviews build on
information gathered during other research efforts, to probe deeper into individual
attitudes and concerns. They are useful when sensitive topics are addressed,
when issues must be probed deeply, when individual rather than group responses
are needed, or when it will prove difficult to gather respondents for a group
meeting.
l Participant observation: In the participant observation method, the educator/
programme implementer participates in the daily life of the community she or
he is studying - observing what is happening, listening to what people talk about,
asking questions in various ways over a period of time.
l Direct observation: Unlike the participant observation method, in direct
observation method, the educator/programme implementer observes, but does
not participate in an event. They usually have a checklist of behaviours to be
observed and a recording format for the observations which may be unstructured
or structured.
l Informal conversations: In the informal conversation method, the educator/
programme implementer takes advantage of any opportunity to converse
informally either individually or in small groups with the members of the
community being studied.
l Ethnographic studies: They combine anthropological techniques to analyze
how specific nutrition practices relate to the larger cultural context. An
ethnographic study may employ several qualitative methods in a complementary
manner to get a holistic picture of the nutritional problem.
Besides the methods enumerated above are other important method used in formative
research is trials for improved practices. What is this method? Let us find out.
Trials for improved practices: Trials for improved practices is an important method
used in formative research. We use this method after we have analyzed and
consolidated findings from rest of the other methods and made recommendations
regarding desirable behaviours. Sometimes we would like to test the recommended
behaviours in people’s homes to see whether the suggested behaviours are feasible
and acceptable by the families or not. This is known as Trials for Improved
Practices (TIPS) and it is a core method of formative research.
In TIPS mothers or primary caregivers are given a choice of recommendations for
action, questioned about their reasons for that choice and then followed up to see
what actually happened after a trial period. In this way the proposed recommendations
are tested in a real environment and information is gathered on their acceptability.
This information helps programme planners to set priorities among the many seemingly 365
Public Nutrition important nutrition practices and messages. TIPs is conducted before the suggested
practices are finalized and recommended as a part of the nutrition education
communication strategy. TIPS thus follows formative research in which the behaviours
to be targeted for change have been decided and counseling is done for each type
of behaviour.
There are some basic steps involved in carrying out TIPS. These are:
l training field personnel in the methodology of TIPS,
l recruiting participants from the community for TIPS,
l an initial visit to gather information, conduct dietary or other assessment as
needed,
l feed back and discussion with teams to analyze dietary information, prepare for
counseling,
l counseling visit to present options for various behaviours, get reactions, negotiate
trial practices; note the practices which family has agreed to try out,
l debriefing to discuss reactions to recommendations and options selected,
l follow-up visits to learn about the reactions to the new practices after a trial
period of two to three weeks. Note the practices which were followed and
those not followed during the trial period from among those selected by the
respondent, and why, and
l analysis, summary and application of results - designing more effective materials
and strategies based on TIPS findings.
Thus, TIPS helps us to fine tune our recommendations, test their feasibility and
acceptability and help develop appropriate messages and materials.
From our discussions above, it is clear that there are a variety of formative research
methods. Interestingly you would realize that, we can use any or combination of
methods to answer the research questions highlighted above. The findings from these
methods are analyzed and consolidated to understand various factors affecting the
behaviour and design materials and strategies. Thus, we can determine the current
behaviours (which may or may not be desirable behaviours) and reasons for those
behaviours by target audience. We also make recommendations regarding what the
desirable behaviour should be. For example, during formative research, we may find
that “Mothers feed their 6-9month old children, only a small piece of chappati
once a day”.
Based on this observation, we may make two recommendations for optimum behaviours
as: “Feed the child ½ katori of mashed up family foods (cereals/dals/ vegetables)
3-4 times a day”.
“ Feed ½ katori mashed green leafy vegetables or yellow fruits/vegetables once
a day”
Now, we would like to test whether the recommended behaviours are acceptable
and feasible for people to follow in their own environment. For this TIPS will be
conducted. To continue with the same example as above, we may ask mothers to
try these behaviours as follows:
“Feed the child ½ katori of mashed up family foods (cereals/dals/ vegetables)
3-4 times a day”.
“ Feed ½ katori mashed green leafy vegetables or yellow fruits/vegetables once
a day”
366
After trying these behaviours in their homes, the mother's might come up and say Conceptualization
that only the first behaviour is acceptable and feasible for them but the second one and the Process of
Nutrition Education
is not. So, you will have to consider only the first behaviour as part of your
communication strategy.
We may identify certain factors or barriers which prevent adoption of desirable
behaviours. These factors can be lack of awareness about what, when and how
much to feed the baby and food taboos. Our communication strategy while developing
messages, choice of media and materials would have to take into account all these
factors in order to bring about a lasting change in current behaviours.
We would like to explain that it is very important to list the expected behaviours
in detail. This goal has to be clearly defined, practical and feasible to achieve. We
need to ask ourselves certain questions before we define the expected behaviour.
Let us elaborate on some of these questions now for defining an expected behaviour.
15.7.4 Defining the Behaviour
We should define the expected behaviour in as much detail as possible. This involves
specifying not only what the behaviour should be, but who is to carry it out and
when. We can begin to make judgments about the feasibility of changing a behaviour
once we have considered the following questions:
l Frequency of behaviour: How often should it be performed - daily, every few
days, occasionally, only once? For example, hygiene behaviours such as cleaning
children and washing hands have to be done every day. They will be more
difficult to promote than a behaviour such as giving mega vitamin A doses that
have to be given only twice in a year.
l Easy or difficult : How complicated is it to carry out - is it very simple or does
it require learning new skills? For example, breastfeeding is simpler than
complementary feeding.
l Similarity with existing practices : How similar or compatible it is to existing
practices - is it completely new, or does it show some similarities? For example,
making a rice gruel may be more compatible with existing practices than making
Oral Rehydration Solution (ORS). Also, not giving water to an infant before 6
months of age may be incompatible with existing practices.
l Resources available: How much does it cost, in time, money or resources to
carry out the behaviour? Complementary feeding involves time and resources,
which are not easily available.
l Felt need of the community : Does the behaviour fit in with a felt need of the
community? For example, taking iron folic acid tablets (IFA) in pregnancy may
not be the felt need of the community.
l Impact on nutritional status : How much impact will the behaviour have on
nutritional status - a great deal or very little? For example, deworming may
show visible impact while change in dietary behaviours may show impact over
time.
l Long or short term outcomes: Will beneficial effects be observed in the short
or long term - within a few weeks, months or years? For example, weekly IFA
supplementation to anaemic adolescent girls may show improvement in
haemoglobin levels within a few months. While impact of NEC to mothers
towards improved complementary feeding behaviours in terms of improved
nutritional status of infants, may take longer duration.
Remember, we need to pay attention to these minute details of a behaviour otherwise
it will be difficult to set clear goals for expected behaviours and bring about a
change in the behaviours.
367
Public Nutrition So we studied how formative research would help us understand various factors
influencing behaviour. It would also help to create appropriate messages and materials
for the nutrition education programme. Results of TIPS would help us to know
whether the suggested behaviors are feasible and acceptable to the community or
no. This takes us to the next step of formulation of the nutrition education programme
i.e. developing objectives and messages and identifying channels of communication
for the targeted audience. We will read about these in the next unit.
1. What is the importance of formative research?
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........................................................................................................................................................................................
2. List all the methods you would use in formative research.
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3. What kind of questions will you keep in mind while deciding on the expected
behaviour for the families?
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15.8 LET US SUM UP

We leant in this unit that nutrition education, as an intervention, came into prominence
with the realization that malnutrition to a large extent is not only due to inadequate
food availability but also due to faulty food habits, some of them based on food
prejudices, superstitions or taboos, and importantly, lack of awareness of the right
food choices. Thus, nutrition education can make a difference in people’s life by
helping them to make right behaviour changes for healthy living. We also learnt that
nutrition education is vital for policy makers and programme planners. They should
be educated about extent, magnitude and distribution of various nutritional problems
in their community and causes and consequences of these problems. This helps them
to make decisions on programme priorities and allocation of funds. Nutrition education
is unique and at the same time difficult because improved nutrition requires sustained
and repeated individual behaviour. Nutrition educators have come up with various
theories which help in understanding people, their knowledge, attitudes and behaviours
regarding nutrition. The process of nutrition education communication programme
consists of four phases- these are: conceptualization, formulation, implementation and
evaluation. Each of these phases have key elements which are critical in designing
nutrition interventions. We discussed the conceptualization phase in detail which consists
of identifying nutritional problems, analyzing causes and conducting formative research
368 to understand the context and characteristics of the community.
Conceptualization
15.9 GLOSSARY and the Process of
Nutrition Education
Education : implementation of appropriate methods for ensuring the
training and development of an individual.
Medical anthropology : branch of anthropological research studying the factors
that cause, maintain or contribute to disease or illness,
and the strategies and practices that different human
communities have developed in order to respond to disease
and illness.
Quantitative methods : research methods such as surveys that use structured
questionnaires or measurements to quantify conditions and
estimate prevalences.
Qualitative methods : research methods based on anthropological, psychological,
and market research techniques, that use open ended
and unstructured question guides to probe rationale behind
current norms and practices.

EXCERCISES
1. Inadequate nutrition is not only due to inadequate food availability but also due
to faulty food habits, some of them based on food prejudices, superstitions or
taboos, and importantly, lack of awareness of the right food choices. Therefore,
change in behaviour ensures better food choices and healthy nutrition. For
example, a pregnant woman may avoid certain foods not because they are not
available, but it may be due to food taboos.
2. Nutrition education is considered challenging because improved nutrition requires
sustained and repeated individual behaviour. The reason why people eat what
they eat is complex and it involves both cultural and psychological aspects.
Changes in food consumption patterns require shifts in deeply ingrained food
habits established since childhood. Also, in very poor communities nutrition
education cannot be effective without simultaneous increase in real income
3. Various theories of nutrition education are: cognitive – Gestaltist theory,
behaviourist theory, the communication approach theory, diffusion and the social
marketing approach theory. According to the cognitive-gestaltist theory, education
is seen as a process of self-development whereby the individual takes control
of his/her environment. Behaviourist theory is based on the premise that the
inner cognitive experience is not the only determinant of behaviour. Behaviour
is determined by the environment, which may consist of competing forces to
provoke and reinforce unhealthy behaviours. The communication approach theory
states that the receiver is selective in his response to the communication, the
factors responsible for this selectivity being the individual’s psychological
orientation. Diffusion is described as a special type of communication whereby
innovations spread to the members of a social system. In a free choice situation,
diffusion of innovations occur more effectively when the sender and the receiver
are alike in personal and social characteristics. Social marketing approach theory
is based on the application of commercial marketing principles to social cause.
4. a. False. As people with same level of education, age, sex respond to same
message in a similar fashion.
b. True
c. False. Social marketing deals with social causes while consumer marketing
deals wih servies for profit. 369
Public Nutrition d. True
e. True
1. The basic components of communication process are: receiver, communicator,
message and the feedback. The receiver receives the message and wants to
understand the message. The communicator communicates the message verbally,
in writing or through non verbal signals. Message consists of what is actually
communicated. The person who receives the message provides feedback.
2. The process of nutrition education consists of conceptualization, formulation,
implementation and evaluation. In the conceptualization phase, we determine the
type and extent of nutritional problems, identify the population groups at risk and
analyze the causes of nutritional problems. In the formulation phase, we give
shape and structure to the elements we conceptualized in the conceptualization
phase. In the implementation phase we actually carry out activities in the field
with the community. Evaluation is the measurement and assessment of the
success of a communication program in reaching its goals.
1. Formative research helps to understand the role of culture, social change and
economic factors in determining behaviours. The results of formative research
aid programme planners in formulating measurable objectives and realistic
strategies for the communication programme.
2. Different methods which can be used in formative research include Focus
group discussions, observation, Informal conversation, ethnographic studies, in
depth interviews and trials for improved practices.
3. The kind of questions that we will keep in mind while deciding on the expected
behaviour for the families cover various aspects such as: frequency of behaviour
indicating how often should it be performed. easy or difficult showing how
complicated or simple is it to carry out the behaviour, similarity with existing
practices in terms of how similar or compatible it is to existing practices,
resources available indicating how much does it cost in terms of time, money
or resources to carry out the behaviour etc.
370
Nutrition Education
UNIT 16 NUTRITION EDUCATION Communication
Programmes: Formulation
COMMUNICATION
PROGRAMMES: FORMULATION
Structure
16.1 Introduction
16.2 Setting Objectives of a Nutrition Education Communication Programme

16.3 Identifying a Target Audience
16.4 Designing Messages
16.4.1 Essential Elements of a Message Design
16.4.2 How we Design Persuasive and Coherent Messages?
16.5 Choosing the Media and Multi-Media Combinations

16.5.1 Face-to-Face or Interpersonal Methods
16.5.2 Mass Media Methods
16.5.3 Traditional Media Methods
16.5.4 Criteria for Selecting Methods
16.6 Development of a Communication Strategy
16.7 Let Us Sum Up
16.8 Glossary
16.1 INTRODUCTION
In the previous unit 15, we briefly discussed about the process of Nutrition Education
Communication (NEC). These processes are conceptualization, formulation,
implementation and evaluation. We discussed in detail about the conceptualization
and enumerated different elements of nutrition education communication. In this
unit, we will study in detail about formulation of nutrition education programme.
Formulation here means to give shape and structure to the different elements
conceptualized during the process of nutrition education. Thus, we would learn how
we design a nutrition education programme. We will begin by learning how specific
objectives of a nutrition education programme should be set. How to identify the target
audience for nutrition education? How to design messages and choose media for delivery
of messages? These are the other aspects covered in this unit. We will conclude this unit
by discussing how we can develop a strategy to communicate our messages to the target
audience.
Objectives
l explain the importance of setting objectives for nutrition education communication

(NEC) programme,
l identify the target audience for NEC, based on specific criteria,

371
Public Nutrition l enumerate the criteria for designing effective communication messages and selecting
appropriate channels, and
l develop skills to develop a communication strategy.
16.2 SETTING OBJECTIVES OF A NUTRITION

EDUCATION COMMUNICATION
PROGRAMME
We have read in the previous Unit and also earlier in Unit 7 that for identifying an existing
problem, we conduct a nutritional assessment. Nutritional assessment of the community
can give us information on the existing nutrition and health problems in terms of quantitative
data. For example, if through the nutritional assessment we determine that only “3% of
infants 6-9 months of age are initiated into complementary foods in a particular community”,
then we may like to see an improvement in this practice in a given period of time as a
result of our nutrition education programmes. So, we may set up an objective saying that
at the end of two years 35% of infants 6-9 months of age would initiate complementary
foods. However, you would realize that, objectives of the NEC programme can be set at
different levels like nutritional, educational and communication. These objectives must be
quantifiable and consistent over the life of the programme. Let us study in detail about the
different levels of these objectives. We shall begin with nutritional objectives.
A. Nutritional objectives
The primary objective of a nutrition intervention programme is the nutritional improvement

of the target group as measured by the indicators of nutritional status. Nutritional status is
a complex phenomenon which is influenced by many factors external to an educational
intervention. The time frame within which different indicators are affected by interventions
differ. The nutritional objectives would therefore be defined with short term and long
term objectives. If we design an educational programme aimed to change behaviour in
the short term (for example, improving complementary feeding practices of 6-9 months
old infants) within the long term objective of improving nutritional status (for example
improving weight-for-age), then we will have to see that the external factors which affect
the nutritional status are favourable. These external factors, for example , are, improved
food production, availability of food and improved health facilities. You know that all
these are conditions which are outside the control of communication intervention. Thus,
short term objectives can be achieved based on the interventions which are independent
of external factors. For example, improving awareness in mothers about nutrition. You
may realize that it is important to set nutritional objectives in measurable terms but
understand that the long term objectives will be achieved only when factors external to
communication interventions are conducive to their achievement.
Let us look at the educational objectives, now:
B. Educational objectives
These objectives are concerned with changes in behaviours of the target population. The
specific objective of a NEC programme is to bring about lasting changes in the behaviour
affecting nutritional status. Adoption of new behaviour depends upon many factors external
to communication programme. Educational objectives should be operationalized as far as
possible. These provide the basis for preparation of an objective evaluation of the
intervention. To be operational, an educational objective should state clearly the
following points:
-- what observable behaviours will indicate that the objective has been achieved?
372 -- who will show the various behaviours?

-- what will be the results of the new behaviour? Nutrition Education
Communication
-- under what conditions will the behaviour be shown?, and
-- what criteria determine that the desired result has been achieved?
We can also have intermediate objectives, which are concerned with changes in motivation,
knowledge, self efficacy and the skills required. These objectives can be achieved
independent of the external factors.
Let us next look at the communication objectives.
C. Communication objectives
The communication objectives relate to exposure of the target population to the message
and its retention through various channels of communication. The goal of any
communication programme, you would agree, should be to bring about a lasting change in
the behaviour of the population. You should remember that in the field of communication,
the methods are as important as the results. For example, we can have two communication
programmes which achieve the same objectives of message retention. The first programme
may do so due to authoritarian approach which results in a relationship of dependence on
the media while the second programme may be participatory and encourages the population
itself to make informed decisions to solve their problems. We would prefer the second
communication programme. Having learnt about different kinds of objectives, we can
develop a hierarchy of objectives as shown in Table 16.1.
Table 16.1: Hierarchy of objectives in a nutrition education

communication programme
Types of Objectives Examples
General objectives l x% of target audience would have improved

(long term, nutritional) nutritional status by the end of five years.
Specific educational objectives l x% more of the target audience compared to

(change in behaviour, short baseline will report introducing their children
term nutritional) to complementary foods at 6 months.
Intermediate objectives l x% more of the target audience compared to

(changes in knowledge, baseline will state that children need to start
motivation etc.) on top foods (complementary foods) at 6
months or will state where to obtain ORS
packets or will demonstrate knowledge of the
growth monitoring chart and state that when
the curve begins to descend and the child
needs special help in feeding.
Communication objectives l Compared to baseline, x% more in the target

(exposure and retention of audience would have heard a radio
messages) programme, or possess a growth chart, or have
attended anganwadi sessions within x months
of communication activities start-up.
Thus, you learnt that we can set nutritional, educative and communicative objectives
depending upon the problems identified in the nutritional assessment. These objectives
could relate to exposure to media, knowledge, behaviour and outcomes of nutritional
situation. Every NEC programme should specify quantifiable objectives in the beginning
of the programme.
373
Public Nutrition You can see in the cited example above, that we are using the term target audience in
our objectives. You learnt in the previous unit that we generally name vulnerable groups
for nutrition education as target audience. There may be other groups also in the community
who may be considered as target audience. Let us learn more about this in the coming
section.
16.3 IDENTIFYING A TARGET AUDIENCE

The formulation phase , we learnt earlier, also deals with identification of target audience.
What do we mean by target audience? Target audience is the population with whom
we communicate for change in behaviours. You know that an individual’s behaviour is
extremely important for his or her health. However, it is not always the individual who
makes the decisions. We often find that other persons in the family and community
influence a person’s behaviour. For example, mother or mother-in-law will influence
what food should or should not be given to an infant. Communications should thus be also
directed at the persons who make the key decisions in the family and community i.e. the
‘gate keepers’. The target population of a NEC programme is, therefore, made up of
different groups. These can be vulnerable groups and target groups. The vulnerable
group in fact may be the target group but not always it is so. For example, pregnant
women in a NEC programme are the vulnerable population, as well as, the target audience
for education. But this is not the case for vulnerable population of 0-5 year old children.
The target audience for this group is their mothers or grandmothers. The target audience
can be further divided into three segments. These are primary, secondary and tertiary
audiences. Let us review these in a little detail.
1) The primary target audience: These are the individuals who would actually change
their nutrition health practices. For example, mothers of young children who would
modify their behaviour to feed their children.
2) The secondary audience: These are the people who can be motivated to teach,
support, and reinforce the practices and beliefs of the primary audiences. Examples
of secondary audience are health care providers, family and friends, and popular
public figures. Few communication programmes are successful if they ignore the
potential of these groups.
3) The tertiary audience: These are the decision-makers, financial supporters, and
other influential people in the community such as pradhan or school teachers. They
can facilitate the communication process and behaviour change and make the
programme a success.
Thus, target audience consists of primary, secondary and tertiary audience. Nutrition
education communication planners must use the results of demographic, socio-
economic, and epidemiological research to determine different types of audiences. We
need to clearly spell out the specific audience we need to target during the NEC
programme.
In child survival and nutrition programmes, the primary audience generally consists of
caretakers (mothers), grandmothers, and sometime- older siblings. However, in an area
where service providers have limited knowledge and acceptance of these skills related
to the new practices, planners may also want to consider health workers, supervisors, or
other opinion leaders as the primary audience for the first stage of the programme. Since
there is a large category of people involved with programme implementation, planners
usually segment these audiences. For example, urban mothers may need a different
communication strategy and different educational materials than rural mothers. Given
limited time and resources, planners must designate the audience segment most critical
to programme success. This may be a geographic or socio-economic group considered
374 at highest risk, one with low access to nutrition care services, one which can be most
effectively reached with limited resources or an existing outreach system, or the segment Nutrition Education
which is most inclined towards initial adoption of new behaviours. Communication
In our discusion so far, we have studied about how to set objectives and identify target
audience. The next step in formulation is how to design messages. We will study this in
the next section. But first let us recapitulate what we have learnt so far in the check your
progress exercise 1.

1. What is the formulation phase of nutrition education communication process?
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2. Enumerate the different types of objectives one needs to set for a NEC programme.
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3. Mention the different types of audience who can be targeted for nutrition education.
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16.4 DESIGN MESSAGES

We studied earlier that formative research is crucial and it helps to determine the current
behaviours of the target audience and the factors affecting these behaviours. As a result,
we identify the gaps and give recommendations for desirable behaviours. Now comes
the challenging task as to how do we put these recommendations across to the people.
We want the target audience to improve upon the current behaviours so that it leads to
improved nutritional and health status. You may recall studying earlier that results of
formative research also help us to identify different channels of communication for the
target audience. We are now ready to develop appropriate messages and support materials
for the nutrition education programme.
Before we go any further, we need to first understand, what we mean by messages,
media and support materials. Let us find out.
l Message is the formulation of an idea or concept to be transmitted to a specific
population ( for example, breast milk is the best food for infants)
l Media is the channel of communication through which the message is transmitted
( for example, counseling, group discussion etc.), and
l Supports are the materials on which the message is transmitted (for example, flip
charts, radio programme etc.)
Having distinguished between message, media and support materials, let us now review
the process of developing these elements. In developing messages, channels of
communication and support materials we need to ask certain preliminary questions to
ourselves, for example, for developing: 375
Public Nutrition l messages, the first question we could ask is what words should be used and in what
order?
l media, we could ask, what type of media? What is the optimal media mix for a
particular situation?
l support materials Which materials to use, what colours and what pictures/images?
You would realize that all these questions are interrelated. The contents of the message
influence the choice of media and support materials. These, in turn influence how
the message is formulated. Selection of support materials is dependent on choice of
media. For example, if we want to counsel the rural illiterate women, then we may
develop poster, flip charts etc. If we want to use mass media such as radio, we may
develop script for a radio programme. We will learn about effectiveness of various
media to different target groups later in this unit. However, whatever be the message,
it is important that the message be persuasive and coherent.
So, then how do we design messages. Let us first discuss the essential elements of a
message design and how we design persuasive and coherent messages conveying the
specific recommendations to the target audience.
16.4.1 Essential Elements of a Message Design

For a message to be coherent, persuasive and effective, the essential elements include:
l Content – this includes the problem identification, target audience, resistance points,
solutions and required action.
l Design – the design factors such as use of single ideas, using language that is
relevant, portrayal of characters with which the target audience can identify or
relate themselves.
l Persuasion – that is dispelling doubts and reducing the chances of the doubts acting
as a barrier to action.
l Memorability – that is, idea reinforcement, minimizing distraction and using repetition
as a strategy.
Thus, messages designed should consist of what is actually communicated, including
the appeals, words, pictures and sounds that we would use to get the ideas across to
the target audience. We would like our messages to be persuasive and coherent so that
they are effective in changing attitudes and behaviours of the target population. But then
how do we design persuasive and coherent messages? The next section focuses on this
aspect.
16.4.2 How we Design Persuasive and Coherent Messages?

We learnt earlier that a well designed message should reach the target audience. Although
there is no one formula for effective message design, there are several useful guidelines.
These are enumerated here for your consideration:
l Nature of the advice given: A message will only be effective if the advice presented
is relevant, appropriate, and acceptable and put across in an understandable way.
l The type of appeal: The appeal is the way we organize the content of the message
to persuade or convince people. Let us see the different types of appeals:
Fear: A message may try to frighten people into action by emphasizing the serious
outcome from not taking action. Symbols such as dying persons, dead child or mother,
and skulls may be used.
Humor: The message is conveyed in a funny way such as a cartoon or an animation.
376
Logical/factual appeal: The emphasis in the message is on conveying the need Nutrition Education
for action by giving facts, figures and information. For example giving facts/figures Communication
on the causes of anaemia or malnutrition.
Emotional appeal: Attempts to convince people by arousing emotions, images and
feelings rather than giving facts and figures, e.g. showing smiling babies.
l One-sided message: Only presents the advantages of taking action and does not
mention any possible disadvantages/limitations that may exist.
l Two-sided message: Presents both the benefits and disadvantages (‘pros and cons’)
of taking action.
l Positive appeals: Communications that ask people to do something e.g. breastfeed
your child as long as possible, give ORS to children suffering from diarrhoea.
l Negative appeals: Communications that ask people NOT to do something i.e. do
not bottle-feed your child.
l Actual content of message: This includes the actual words, pictures, sounds that
make up the communication and convey the appeals. In a radio programme the
content would be a mix of the advice given, wording, tone of voices and music. A
poster would contain the basic appeal, pictures, words, photographs, symbols and
colours.
Thus, if we follow these guidelines, we will be able to make our messages persuasive
and coherent for target population.
Another important point which you need to remember is that we cannot overwhelm the
target audience with too many messages, therefore, we need to prioritize the
recommendations and limit them to 2 or 3 messages.
Having designed our messages, next we need to decide on the choice of media and then
develop support materials. You may recall that design of support materials depends upon
the choice of media. Let us now learn about choice of media.
16.5 CHOOSING THE MEDIAAND MULTI-MEDIA

COMBINATIONS
You know that the media are the channels of communication through which messages
are transmitted. We discussed earlier that information about different communication
channels can be obtained during formative research in a community. Thus, while conducting
nutrition education programme, we can make use of these channels in a most effective
way to transmit the messages. What are the different channels of communication one
can use in nutrition education communication? Let us find out.
Nutrition/health information can be communicated through many channels to increase
awareness and assess the knowledge of different population about various issues, products
and behaviours. Channels might include:
l Interpersonal – face-to-face or interpersonal methods include all those forms
of communication involving direct interaction between the source and the receiver.
For example, individual discussions, counseling sessions or group discussion,
community meetings and events.
l Mass Media communication such as newspapers, magazines, booklets, leaflets,
exhibitions with charts, models, posters, radio, television and audio visual aids like
films and documentaries.
l Traditional channels/folk media such as story telling, play acting, song with a message,
hand puppets or string puppets and others. 377
Public Nutrition Figure 16.1: Illustrates the different channels/media one can use for communication
Nutrition Communication
  
Interpersonal communication Mass media Traditional
   
Individual approach Group Approach - Television
- Personal contact/ - Lectures - Radio, recording - Folk music and
interviews - Films/tape dance
- Demonstration
- Home visits - Newspaper - Puppetry
- Discussion methods
- Personal letters/ - Other printed matter
- Group
telephones
- Panel - Journals
- Symposium - Magazines
- Workshop - Exhibition/Melas
- Conferences - Posters/Charts/Bill pasting
- Role play/Drama - Computer/Internet
- Models
- Field visits/Tours
Figure 16.1: Channels of Communication
Let us look at these channels now in detail with their advantages and limitations.
16.5.1 Face-to-Face or Interpersonal Methods

As stated above, face-to-face or interpersonal method include all those forms of
communication involving direct interaction between the source and receiver. In this method,
voice is the main organ of communication, but the use of other support materials is highly
recommended. These support materials can be printed, visual, and audiovisuals. They
reinforce the oral communication between the educator and the target audience.
Interpersonal communication is a very effective way of studying the nutrition problem
and for adapting the necessary messages. It is important for you to know that interpersonal
communication is of considerable importance in any strategy for public education. In fact,
the most successful attempts to change nutritional habits have been based mainly
on interpersonal communication usually used in conjunction with other methods.
Thus, interventions in nutrition education must encourage interpersonal communication.
You would realize that most people working in development programmes are involved in
interpersonal communication. Interpersonal communication may take place in two kinds
of circumstances. These are: One-to-one counseling and group situation. Let us understand
these in detail. We will look at one-to-one counseling first.
a) One-to-one counseling
One-to-one counseling can take place when the caregiver or mother visits the doctor,
health worker or anganwadi worker. These functionaries can listen to the mother/
caregiver’s problems and help her find solution to her/his problems. The messages
given by them should complement those transmitted via other channels of
communication. They can reinforce the messages relevant to the public.
b) Group discussions
Group discussion involves face-to-face interaction with a group of people. Sometimes
378 it is desirable to work with groups of people not only to save time and money but also
to benefit from group dynamics. Examples of face-to-face group discussions are: Nutrition Education
lecture, demonstration, meetings, community events, role play etc. Face-to-face Communication
group discussion can be a small group (less than 12 persons) counseling, intermediate
group/lecture (between 12 and 30) and large group lecture/ public meeting (more
than 30).
We have looked at the different forms of interpersonal methods of communication. Now
let us get to know the advantages and limitations of face-to-face method of communication.
We shall look at the advantages first.
Advantages of face-to-face methods
The main advantage of face-to-face methods is that it is possible to contact specific
groups, make the advice relevant to their social needs and develop problem-solving skills
and community participation. It is also possible to check that you have been understood
and give further explanations.
The advantage of face-to-face communication over mass media is that it creates
opportunities for questions, discussion, participation and feedback. Let us look at the
limitations, next.
Limitations of face-to-face methods
Face-to-face methods are slower for spreading information in a population because of
the need to mobilize field workers and travel to different communities to hold meetings.
There are not enough educators for the intensive personal contact needed on a mass
scale. Also the communicator may be ineffective if he/she is “ill-informed, uses an
unsuitable approach, or holds a status in the community felt to be inconsistent with his/her
role”. Further, as the size of the group increases, it is more difficult to have feedback and
discussion. In large groups and public meetings usually only a small number take part and
many persons feel shy speaking out. Finally, person-to-person education carried out by
paid workers is difficult to justify in terms of cost-effectiveness.
Having looked at the interpersonal methods of communication, let us next, study about
mass media.
16.5.2 Mass Media Methods
What do we mean by mass media? The term “mass” in mass media means that we can
reach large number of people at a time through the means of communication employed
through this approach. Mass media methods comprise the institutions and techniques
by which specialized groups employ technological devices (press, radio, films,
television etc.) to disseminate symbolic content to large heterogeneous and widely
dispersed audiences. Thus, in mass media methods, the interaction between source and
the receiver is mediated through the visual image, print, verbally or by a combination of
these elements. The source and receiver are never in direct contact in mass media methods.
Mass media include broadcast media such as T.V, radio etc. and print media such as
newspapers, magazines etc. Mass media plays a very important role in creating awareness
and interest in new ideas among general population groups.
You may also be aware about the technological innovations taking place in the world
today and we should not forget the presence of computer in our daily life. In fact,
computers in nutrition communication are becoming very important means to disseminate
information across the globe. The information can be disseminated through internet,
electronic mail (email), chat rooms and multimedia. On internet, we have data base of
various topics in nutrition, research, and reports of programmes and projects conducted
in any part of the world. All these can be downloaded easily on the internet. Nutritional
professionals all over the world are using email to exchange ideas, documents and data.
Email is a very fast, easy and inexpensive means of communication. You might have used
chat rooms to converse with your friends or relatives electronically. Chat rooms are also
a type of electronic communication where several people sitting miles apart from each
other can engage in a face-to-face conversation through the computers. Chat rooms can
be used to discuss nutritional issues and exchange ideas. You must have heard of 379
Public Nutrition multimedia programming used in computers. Multimedia is a computer controlled
combination of text, graphics, sound, photographs, motion pictures and other types of
media. There are many types of multimedia programmes available which can be used in
nutrition communication and nutrition training. The programmes can be used by both
professionals and consumers. Some of these programmes include food service and recipe
management, dietary data collection and nutrient analysis. You might have seen colourful
brochures on the internet promoting a product or services. These are prepared using
multimedia programming. Similarly, nutritional brochures can also be designed using
multimedia and distributed to large groups of people accessing the internet. Satellite based
interactive teleconferencing can also be arranged to discuss nutrition issues and for teaching
students sitting at far off places as is being practiced by IGNOU.
Let us then review the advantages and limitations of mass media. We begin with the
advantages first.
Advantages of mass media
The advantages of mass media include:
l It provides a rapid way to reach a very large (even non-literate) audience.
l It makes good use of scarce manpower.
l Mass media are not only appropriate to inform and to create or reinforce change,
but may also help to motivate and teach.
l It can be inexpensive, at least in terms of cost per person reached.
Next it is the turn of limitations.
Limitations of mass media
Mass media though effective, have certain limitations as well. These are:
l As mass media are broadcast to the whole population, they are not a good method
for selectively reaching specific groups, e.g. grandmothers or teenagers. It is difficult
to make the message appropriate to the special situation of local communities, whose
problems and needs may be different from the rest of the region. Even if a person
hears something on the radio and wishes to change, those around them may pressurize
him or her against change.
l Particularly for large and diverse audiences, mass media alone cannot persuade
people to change deep-rooted attitudes or learn complex skills, since mass
communication cannot possibly have the required cultural, linguistic, and social
sensitivity nor receive individual feedback that will help assure that messages are
relevant, appropriate, and understood by the audience. A well-planned programme
involves a carefully chosen mix of both face to face and mass media methods,
which exploits their different advantages. For example, we can counsel the rural
women on child nutrition. We can also present the information on child nutrition
through a radio programme so that the messages, which she receives through
counseling, get reinforced.
Let us review traditional media now.
16.5.3 Traditional Media Methods
The traditional or folk media are the traditional methods of communication prevalent in a
community. In contrast to the modern mass media, the traditional media are personal,
familiar and more credible forms with which the majority of literate and illiterate individuals
identify easily. There can be three different types of traditional or folk media. These are
folk music, ballad forms of folk and puppetry. In the folk music, there are 300 folk
musical styles in India. These folk musical styles are used in all languages and states in
India. These are entertaining and invite audience participation. Ballad forms of folk
approach involve folk singing. The range of folklore presented through these ballad styles
is extensive and full of variety. Some common forms of ballad style include Burrakatha
(Andhra Pradesh), Villupattu (Tamil Nadu), Alha (Uttar Pradesh), Jugani and Vaar
380 (Punjab), Powada (Maharashtra) and many others. Puppetry has fascinated people of
all ages but children, in particular, for centuries. Puppet shows are an effective Nutrition Education
communication folk approach practiced in many cultures. Puppets come in many forms, Communication
these are string puppets, rod puppets, shadow puppets and hand puppets.
Community gatherings, religious meetings and ceremonies can also provide opportunities
for nutrition-health education. Let us look at some of the advantages of folk or traditional
media. These include:
-- Traditional media is cultural specific and community can easily identify the context
and understand the messages,
-- it appeals at a personal and intimate level,
-- it is available to all at a very low cost,
-- it is flexible in adopting new themes, and
-- it preserves and disseminates the tradition and culture of our ancestors in a lively
manner.
You must be wondering as to how do we choose the right channel of media i.e. face-to-
face, mass media or traditional approach for nutrition education programmes. There are
some criteria which we follow for choosing the channel of communication. Let us review
these next.
16.5.4 Criteria for Selecting Methods
We have studied about the different channels of communication in the previous sub-
section. Now the question arises, which method we should select to communicate our
messages? Obviously, that would depend upon the various parameters such as what are
the objectives? Who is the audience? What is the budgetary allocation? Let us look at
these parameters and see how they influence the choice of method.
l The learning objective: Our ‘learning’ objectives would determine if we need to
convey simple facts, complex information, problem-solving skills, practical manual
e.g psycho-motor skills, or simply target for an attitudinal change? For example, if
we want to teach mothers to recognize what a malnourished child looks like, we
would perhaps use media that include visuals such as posters and chart etc.
l Characteristics of the audience: We will have to know what are the characteristics
of the audience that will affect choice of channel? e.g. age, experience in life,
education level, previous exposure to media, ownership of radio/TV, listening,
watching and reading habits, familiarity with different media, traditional
communication methods which are already in use in community.
l Characteristics of different methods: We will have to know how much will the
different methods cost, including initial costs and operating maintenance? How many
staff members and what levels of skill are involved in using the method? What field
requirements will affect the use of the equipment, e.g. need for electricity, storage
and transport needs.
l Costs: We have to ensure availability of funds for initial purchase, spare parts and
maintenance, charges for electricity, paying for trained staff for media production,
maintenance and implementation.
l Other programme considerations: There will be other programme considerations
for which you will have to answer many questions like - if you need a visual dimension,
e.g. a picture, to explain your point? Is sound necessary? How aggreable is the
community of new ideas? Will they be resistant to your advice? How urgent is your
time scale? Is it a short or long-term priority? Do you want to develop community
participation?
So we have looked at criteria , which when considered, would help decide what
communication channel we can choose to communicate our messages. You would realize
that it is always better to use several channels to transmit the same message than a single
channel. Why? Using several channels will reinforce the message delivery and is more
likely to be effective for behaviour change. So how do we do that? There are two aspects
which we can look at to consider which media is best suited to bring about a change in 381
Public Nutrition behaviour. First is its relative strength and weakness in relation to improving the various
parameters of nutrition education and the other is how effective it is with different types
of audience. Let us look at each aspect one by one. Let us look at the strengths and
weakness of various media.
A. Strengths and weakness of various media
It is important for you to understand that each channel has a specific impact on us. For
example, using a specific channel of communication, we may gain in knowledge, we may
change attitudes and/or we may retain a mental image of what we see or develop verbal
or demonstration skills. These are the factors or parameters which will contribute to
change in behaviour. We may acquire various parameters in varying degrees depending
upon the type of media used in the nutrition education programme. This translates into its
strengths and weaknesses. Table 16.2 highlights the various parameters and the relative
strengths of media in changing various parameters of nutrition education.
Table 16.2: Relative strengths of the media in changing various parameters of
nutrition education
Acquisition of parameters
Channels of
communications Knowledge Mental Concepts Methods Verbal Psycho- Attitudes
Image and skills motive
Principles skills^
Only verbal ++ + ++ ++ ++ ++
communications ++
Verbal ++ + ++ + ++
+++
communication+ +
fixed image
Verbal
communication+ +++ +++ +++ +++ ++ +++
moving image ++
Verbal
communication+ ++ +++ + ++ + ++
3 dimension object +
Verbal +++ + ++ ++ + ++
communication+ +
printed material
Verbal ++ ++ ++ +++ ++ ++
communication+ ++
demonstration
Radio (non ++ + + ++ ++ ++
interactive) +
Television +++ ++ +++ ++ +++ +++

++
Written press ++ + ++ ++ + ++
+
Poster ++ ++ + ++ + ++
+
^psychomotive skills include how a particular message influences your mind
Key : Good effect +++ Little effect +
Moderate effect ++
Having gone through Table 16.2, it is clear that different channels of communication
adhere to different parameters. If the channel of communication is only verbal
communication like lecture or discussion, then there is moderate effect on acquiring
knowledge and verbal skills to the target audience but little effect on mental image. Mental
image, as you know, has a big impact in retaining the messages. But if we use verbal
communication with a moving image like lecture with a film, then acquisition of knowledge,
382 mental image, procedures, and attitudes is greatly enhanced. Thus, each channel has
relative strengths and weaknesses in relation to improving specific parameters of nutrition Nutrition Education
education. Based on these characteristics of each media we can develop a plan for Communication
multimedia combination for dissemination of messages.
We will now look at the second aspect in choosing media, that is the effectiveness of
each media in reaching a specific target group.
B. Effectiveness of each media in reaching a specific target group
It is important for us to know that different channels of communication are effective in
reaching different target groups. Table 16.3 highlights the effectiveness of different
means of communication in reaching various target groups like rural women, urban
population, village leaders, field workers etc.
Table 16.3 Methods Of Communication for different target groups
Groups Rural Rural Urban Field Village School General
communication Women Men Population Workers Leaders Children Public
Television - - Very - - - Less

Effective Effective
Radio Less Very Very Very Very Less Very
Effective Effective Effective Effective Effective Effective Effective
Written Press - - Less Less - Less Very
Effective Effective Effective Effective
Posters Less Less Less Very Less Less Very
Popular theatre Very Very Less Very Less Very Less

Video - - Less Less Less - Less

Interpersonal Communication
Practical Very Less Less Less - Very -

demonstration Effective Effective Effective Effective Effective
Fix film Very Very Very Very Less Very -

Effective Effective Effective Effective Effective Effective
Audio cassette Very Very Very Very Very -
Effective -
Personal Very Very Very Very Less Very

Effective Effective Effective Effective Effective -
contact Effective
Flanellographie Very Less Very Very Less Very

Effective
Flip chart Very Less Very Very - Very

Brochures Less Less Very Less Very Less

Effective Effective Effective Effective Effective Effective
Institutional Communication
Meetings - - - Very Very - -
Effective Effective
Information - -
- - Less Very -
notes Effective Effective
Inter-village Less
Less Less Less Very
- Effective -
visit Effective Effective Effective Effective
We can note from Table 16.3 that while using mass media, television as a means to reach
urban population is very effective. Similarly, while using interpersonal communication
with rural women, demonstration and use of flip charts may be very effective. Thus, we 383
Public Nutrition may want to use a specific channel of communication for a given target group in order to
make the communication effective.
Having learnt about strengths of various media and their effectiveness in reaching different
media, we can next move on to learning how we can determine the best multimedia
combination.
C. How to determine the best multimedia combination
First what do we mean by a multimedia combination? A multimedia combination involves
a systematic and organized use of several channels of communication. If we use
several channels of communication in such a way that each one of them reinforces the
other, so that their collective impact is greater than the sum of their influence taken
separately, their overall impact on the education intervention is increased. This principle is
also known as synergy. It is well known that interpersonal communication is the best way
of communicating with the target audience. The basis of a media mix is the interaction of
interpersonal communication with mass media communication. An essential element of
many successful nutrition education programmes has been to use a multimedia combination.
We know that each channel of combination is specific in its own way. The challenge is to
find the best combination which can result in the realization of objectives. For example, as
we would note from Table 16.3 that if we want to reach a group of rural illiterate women,
we can use popular theater or traditional/folk music to communicate specific message.
We can also communicate the same message through counseling and practical
demonstration. This will have a synergic effect and lead to reinforcement of messages. It
can, therefore, be seen that the ideal approach is to select not one, but several
complementary media to maximize the potential for a successful intervention.
Having looked at the various channels to deliver the messages, we can now look at how
we communicate our messages to the target audience in a systematic way. This brings
us to a very important step of designing the nutrition education programme, that is,
development of a communication strategy for behaviour change. Let us look at this now.
16.6 DEVELOPMENT OF A COMMUNICATION

STRATEGY
A communication strategy is a planned and systematic way of communicating messages
to the target audiences. We can have a clear and well defined strategy to communicate
our messages, based on the key elements discussed above. A communication strategy
can guide us about behaviours to be changed in the target audience, and messages and
materials to use through various media. There are nine components, which form part of a
communication strategy for behaviour change. These components are derived from our
discussions above. These also serve as a basis for the detailed implementation plan.
These components are:
1. Ideal behaviours
2. Current behaviours
3. Feasible behaviours
4. Barriers to behaviour change
5. Audience
6. Messages
7. Media and materials
8. Activities (e.g. Training, community mobilization, advocacy, counseling, negotiation
during group meetings and household visits)
9. Monitoring and evaluation
Let us briefly review these components one by one.
Ideal behaviours: Ideal behaviours are the recommended behaviours which the target
384 population should follow to achieve optimum health and nutritional status. These
recommendations are those which are suggested by the experts in the area of nutrition Nutrition Education
and health. For example, a major recommendations for infants 6-9 month old is that “in Communication
addition to breast milk, the child should receive complementary foods at least 3-4 times
a day”. Ideally, we would like all mothers to follow this recommendation so that the
infants are healthy.
Current behaviours : Current behaviours are the behaviours currently followed by the
target population. It may or may not be ideal. For example, current behaviour of a six
month old child may be that he/she has not started any complementary foods yet. He/she
is on mother’s milk only.
Feasible behaviours: Feasible behaviours are the behaviours which have been tried by
the target population during trials of improved practices (TIPS) as discussed in the earlier
Unit 15 and found acceptable. The feasible behaviours guide us to develop our messages.
Barriers: These are the resistance points which need to be overcome with while delivering
messages during various channels of media. For example the barriers in infant feeding
may be lack of awareness and traditional beliefs.
Audience: The target audience for communicating messages, as you may recall studying
earlier, can be primary, secondary and tertiary. Continuing with the same example of
feeding complementary foods to children 6-9 months old, it would be mothers of infants
0-12 months of age, anganwadi workers, mother’s groups and families, who would form
the target audience.
Messages: We can develop our message accordingly. Using the same example as above,
our message can be “Start feeding 1-2 tablespoons of soft mashed cereals and vegetables
once a day”. “ Mother’s milk alone is not sufficient to meet the growing needs of infants
after 6 months - the infants need complementary foods”.
Media and Materials: From the findings of the formative research, we learnt about the
channels of communication most popular in our community. For example, we may
determine that the most popular channels of communication are face-to-face or
interpersonal methods. Then we use counseling and group meeting as methods to
communicate our messages. We can use the materials such as flip charts, flash cards
and posters.
Activities: When we implement the nutrition education programme in the community,
then we will be conducting certain activities such as training, community mobilization,
counseling etc. We will discuss some of these activities in detail in the next Unit 17 on
implementation of nutrition education programmes. These form a very important part of
our communication strategy.
Monitoring and evaluation: Finally, we develop a monitoring and evaluation plan and
include in the communication strategy. For example, we might organize review meetings
with the staff implementing the programme on a regular basis to monitor the programme.
For evaluation we might plan an evaluation at the end of the programme to assess if we
have achieved the objectives or not. We have will discuss this in detail in Unit 17 and 18.
Thus, we learnt about how various steps would eventually lead to formation of a
communication strategy. We are now ready to implement the nutrition education programme
in the field. We will study this in the next Unit 17.
1. What are points to be considered for development of effective messages?
................................................................................................................
................................................................................................................
................................................................................................................
385
Public Nutrition
2. Fill in the blanks
a. The different communication channels are ............. , .............. and

............... media.
b. The main advantage of face-to-face communication over mass media is

that it creates opportunities for ...................... and ................. .
c. The advantages of mass media is that it makes good use of scarce..........

3. List any three criteria, you would adopt for selection of communication channels?
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
.........................................................................................................................
4. What do you understand by the concept of multimedia mix?
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
5. What are the different components of a communication strategy ?

................................................................................................................
................................................................................................................
................................................................................................................
16.8 LET US SUM UP

We learnt in this unit that after the conceptualization of a nutrition education programme,
next step is to formulate the programme. Formulation gives shape and structure to different
elements of a nutrition education programme. There are many steps involved in
formulating a nutrition education programme. These steps are: setting measurable and
well defined objectives in a nutrition education programme, identification of target audience,
designing messages and materials and choosing media and media mix. We studied about
how to design persuasive and coherent messages. We learnt that it is always better to
use a combination of media mix rather than single media. A combination of media mix
helps to increase the impact of nutrition intervention. We concluded the unit by elaborating
upon various steps of a communication strategy and we are ready to carry out the
programme in the field.
16.9 GLOSSARY
Attitudes : affective, motivational, perceptive and cognitive lasting set of beliefs
related to a reference group which predisposes an individual to react
positively or negatively to these references.
Behaviour : overt action of an individual.
Culture : a set of rules or standards shared by members of a society which
when acted upon by the members produce behaviour that falls within
a range of variation the members consider proper and acceptable.
386 Print media : a medium that disseminates printed matter.

Nutrition Education
16.10 ANSWERS TO CHECK YOUR PROGRESS Communication
EXERCISES
Check Your Progress Exercise I
1. Formulation phase of nutrition education communication signifies giving shape and
structure to the different elements conceptualized during the process of nutrition
education. It includes elements such as how to set specific objectives of a nutrition
education programme, how to identify the target audience for nutrition education,
how to design messages and choose media for delivery of messages and develop
communication strategy.
2. Different objectives of a nutrition education programme are nutritional objectives,

educational objectives and communication objectives. The primary objective of any
nutrition intervention programme is the nutritional improvement of the target group
as measured by the indicators of nutritional status. Educational objectives are
concerned with changes in behaviours of the target population. The communication
objectives relate to exposure of the target population to the message through various
channels of communication and retention of these messages.
3. Different types of audience who can be targeted for nutrition education are primary
target audience (caratakers, mothers etc.), secondary target audience (family, friends
etc.) and tertiary target audience. Primary such as decision-makers, financial
supporters and other influential persons in the community.
1. Development of effective messages depends on, nature of the advice given, the
type of appeal, and actual content of message.
2. a. face-to-face, mass, traditional
b. questions, discussions.
c. manpower
3 Three criteria for selection of communication channels are: i) The learning
objective, ii) Characteristics of the audience, and iii) Characteristics of different
methods.
4. A multimedia mix/combination involves a systematic and organized use of several
channels of communication in such a way that each one of them reinforces the
other, so that their collective impact is greater than the sum of their influence taken
separately, their overall impact on the education intervention is increased. The basis
of a media mix is the association of interpersonal communication with mass media
communication.
5. Various components of a communication strategy are: ideal behaviours (recommended
behaviors), current behaviour (behaviours currently followed by target audience),
feasible behaviour (behaviours found feasible and acceptable by the families ),barriers
to behaviour change, audience , messages, media, materials and channels, activities
(e.g. training, community mobilization, advocacy, counseling, negotiation during group
meetings and household visits), and monitoring and evaluation.
387
Public Nutrition
UNIT 17 NUTRITION EDUCATION
COMMUNICATION
PROGRAMMES:
IMPLEMENTATION
Structure
17.1 Introduction
17.2 Implementation Process - An Overview
17.3 Production of Communication Support Materials
17.3.1 Need of a Multidisciplinary Team in Production of Support Materials
17.3.2 Pretesting Communication Materials
17.3.3 Large Scale Production of Support Materials
17.4 Designing an Effective Training Programme

17.4.1 Training the Change Agents
17.4.2 Training Strategy
17.4.3 Training Guidelines
17.4.4 Plan for Training Programme
17.4.5 Assessment of Training
17.5 Executing the Communication Interventions

17.6 Social Marketing : A Key to Successful Public Health Programmes
17.6.1 What is Social Marketing?
17.6.2 Social Products and Commercial Products
17.6.3 The Marketing Mix of Social Marketing Process
17.7 Community Participation

17.7.1 Spectrum of Community Participation
17.7.2 Types of Community Groups
17.7.3 The Process of Dialogue in Community Participation
17.7.4 Benefits of Community Participation
17.8 Let Us Sum Up

17.9 Glossary
17.1 INTRODUCTION
In the previous Unit 16, we studied about formulation of nutrition education progamme.
We studied about how to set objectives for the nutrition education programme and
identify target audience. Further, this unit focused on how to design messages, how to
choose media of communication and finally how to develop communication strategies.
Now in this unit, we will discuss the implementation of NEC programme.
We will begin our study with an overview of implementation process. Here we will
highlight three main aspects of implementation process. These are production/ duplication
of communication materials, training and executing a communication intervention. Thus
we will get to know how to produce the communication materials, what is
pretest and why it is important in production of communication materials and how to
produce materials on a large scale. Training of nutrition educators which includes
assessment of training needs and development of training plan is the other aspect
388 discussed in this unit.
Objectives Nutrition Education
Communication
After studying this unit, you will be able to: Programmes:
Implementation
l describe the method of production of support materials,
l elaborate on the purpose of a training strategy,
l explain the plan for a training programme,
l develop skills to conduct communication interventions,
l discuss social marketing, and
l describe community participation.
17.2 IMPLEMENTATION PROCESS - AN

OVERVIEW
Implementation, as you may already know by now, means carrying out activities in
the field. We saw in the previous unit the process of planning a nutrition education
communication programme. The car is all assembled and ready to go. Let us now start
the engine and move ahead on the road to implementation and see what is required
for a smooth journey towards our intended destination, or goal.
There are three main aspects of implementation process. These include:
l Production of communication materials
l Training, designing and conducting a training programme, and
l Executing the communication intervention
Let us briefly review these aspects. We shall begin with production of communication
materials.
17.3 PRODUCTION OF COMMUNICATION

SUPPORT MATERIALS
We learnt in the previous unit that based on the findings of formative research and
trials of improved practices (TIPS), we design our messages and choose our multimedia
mix. The next step now is to design and develop the communication support materials.
Support materials, as you may recall reading earlier, refers to materials on which
the message is transmitted (for example, flip charts, posters etc.). In the implementation
phase, we determine various aspects related to the production, distribution and use of
communication materials such as how much material we produce, who produces these,
who uses them, how they are distributed, methodology of their use and the total costs
involved in all these activities. Therefore, there are three aspects involved in
production of support materials. These are: need of a multidisciplinary team to
develop materials, pretesting the materials and large scale production of materials. We
will study each of these in detail in the following sections. Let us start with need of
a multidisciplinary team.
17.3.1 Need of a Multidisciplinary Team in Production of Support

Materials
The development of materials for communication calls for members of a multidisciplinary
team to work in close collaboration with each other. This is because it is very rare to
see any one professional having the knowledge and the skills to develop communication
materials. There are very few nutritionists who are also the graphic artists. We need
a team consisting of the nutritionist, creative or graphic artist, technicians and the
overall coordinator. The team members should know and accept the notion of a team 389
Public Nutrition effort where each person’s contribution is subject to constructive criticism for the
overall good and success of the materials. The role of each team member should be
clarified as follows:
l The nutritionist is responsible for the message content.
l The creative or graphic artists are concerned with design, formulation of the
messages and their translation into appropriate materials. They are responsible for
the appeal, tone and format of the message.
l Technicians are responsible for creativity, particularly when it involves an audio-
visual material. The producer works with a team of technicians concerned with
sound, editing etc.
l An overall coordinator coordinates the work of artists and technicians.
Thus, we can place our messages in appropriate support materials with the help of a
multidisciplinary team. You can see that no single member of the team above has the
required skills or knowledge to develop support materials, that is why we need a
multidisciplinary approach.
Once we develop our draft support materials we are ready to pretest it in the community
before we produce it on a large scale production. Let us now discuss pretesting the
materials.
17.3.2 Pretesting Communication Materials
We start by answering the question. What do we mean by pretesting? Pretesting is
defined as an activity conducted to predict the impact of a communication material/
message prior to its implementation. Once messages are drafted and a series of
communication materials are prepared, pretesting is done with representatives of the
intended audience in order to test the message and visuals. Next, why do we need to
pretest the materials? Pretesting is crucial because audiences, especially those, who
have had little exposure to printed materials can easily misinterpret illustrations and the
text. Hence, it provides an opportunity to test the effectiveness of the materials.
Pretesting also helps in training the project staff. The setting in which the pretesting
is conducted is important. The greater the similarity between the setting in which the
pretest is conducted and the setting for implementation, more are the chances of the
pretest predicting the correct responses from the audience.
How do we conduct pretesting?
During pretesting, an interviewer shows the materials to the members of the target
audience and asks open-ended questions to learn if the message is well understood and
acceptable. We can conduct individual pretesting or group pretesting. Let us see how.
Individual pretests and group pretests
Pretesting can be done with both individuals and groups. Whenever possible, pretests
of materials for groups with low literacy skills should be conducted with only one
member of the target audience at a time to ensure that respondent answers are not
influenced by other people. Pretest respondents must be representative of the target
audience. We should ask questions that are “open-ended” rather than “close-ended”
and those that are “probing” rather than “leading”.
Group pretests are sometimes used as an alternative to individual interviews. Group
pretesting can provide invaluable information when testing materials intended for literate
audiences. Group pretesting is also particularly effective for pretesting materials containing
primarily textual messages or other materials such as film scripts, audiocassettes,
videos, rehearsals, or live performances.
Pretesting should be done before the materials are finalized so that they can be revised
based on the audience’s reactions and suggestions. Most materials must be pretested
and revised several times. Each new or revised version is tested again until the
390
material is well understood and acceptable to the target audience. Pretest sites must Nutrition Education
be similar to those of intended audience for communication so that there are greater Communication
Programmes:
chances of the pretest predicting the responses of the audience. Implementation
During pretesting we need to ask certain questions to help guide us how well we
communicate with our audience. Let us find out what these questions are. These are:
l Do they like the materials?
l Do they understand the symbols and pictures correctly?
l Do they get the message right away, or are they confused by the way things are
portrayed, or by unnecessary details?
l Do they see the relevance of the picture or situation portrayed, to their own lives
and their own needs?
l Does any part of the picture embarrass people?
l What significance is attached to the different colours?
Seeking answer to these questions will help us decide on key issues to be kept in mind
while conducting pretesting.
Now that we have pretested and finalized the development of messages and materials, it
is time to produce these on a commercial scale. Let us find out how to do that, it next.
17.3.3 Large Scale Production of Support Materials
Once the draft model of the support materials has been finalized, we are ready to
produce these on a large scale. We have to decide where and how these would be
produced. The selection of a production unit will depend upon the availability of resources
in the country, district or village. A private company may be selected or in other cases
a production unit of a government institution may take up the work of production. Cost
is a very big factor which has to be considered while producing materials on a large
scale. We should remember that we need to obtain the optimum balance between
quality and price while producing large quantities of communication materials so that
we have the best quality materials at reasonable prices. There are many type of costs
involved. We will give you some guidelines on the various costs. These are listed as
follows:
l Development related costs : Development related costs include fees for the
graphic artist for a graphic production or fees for the producer in an audiovisual
production.
l Cost of materials : Costs of materials include the materials bought or rented for
developing support materials. For example, paints, charts, audio, video equipment
etc.
l Pretesting costs : Pretesting cost depend upon the method of pretesting done.
These include traveling expenses, investigator’s fees, compensation for persons
interviewed, processing of data and writing up reports.
l Cost of revising the materials : These include costs for technicians, artists and
the materials bought and rented.
l Cost of producing : This cost involves producing the materials on a large scale.
Many a times there is an economy of scale for producing large amount of graphic
or print materials. Market should be scanned to identify best offer for the unit
price.
l Dissemination costs : These costs are determined when the audio visual aids like
T.V. and radio are used for disseminating the messages.
Other than these, there are certain administration costs involved in executing all these
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Public Nutrition activities. Thus we have to take into account these costs while producing the support
materials in draft form and on the commercial scale.
Now that we have the communication materials ready, people are ready to use
them in the field. But the crucial question here is, are the people trained to take up
this task? Let us now look at the training and how we design an effective training
programme, next.
17.4 DESIGNING AN EFFECTIVE TRAINING

PROGRAMME
A major aspect of implementation is training the change agents for the purpose of
educating and communicating for behaviour change among the target audience.
Behaviour analysis supplies principles for effective learning strategies in programmes
such as nutrition communication where not only knowledge, but practice is criterion
of success. For designing and conducting an effective training programme, we need
to train the educators or change agents, establish a training strategy, develop training
guidelines and formulate a training plan. We will study each of these aspects in detail
now. Let us start with training the change agents.
17.4.1 Training the Change Agents

The major step in implementation is the training of the educators who are actually
going to conduct the nutrition education programme. You should know that it is the
various members of the government, non government organization and community
who are actually going to conduct the nutrition education programme. It is necessary
that implementation of a nutrition education programme be carried out by a
multidisciplinary team. Why? We discussed earlier in Unit 2 that there are multiple
causes of malnutrition, accordingly, we need representatives/members from different
departments/sectors, for example, agriculture, water and sanitation etc. who will be
involved in implementation process. We could also have teams involved at various
levels e.g. national, regional and local levels. At the national level, we can have a
team composed of a representative from Planning Commission members from other
Ministries already active in nutritional education e.g. agriculture, food processing,
health and family welfare, forest, education, rural development and NGOs working in
the country, certain private companies (e.g. the companies concerned with production
and/or the marketing of food stuffs) the sponsors, as well as, recognized representatives
of the population. At the district / regional level, we could have members from the
local governments and their counterparts represented at the national level. At local
level, intersectoral and interdisciplinary representation will be assured by the presence
of local panchayats, school teacher, the health officer, the anganwadi worker or the
supervisor, representatives from local womens’ groups and NGOs. The presence of
recognized representatives from the population will guarantee a mechanism for
participation and in the decision making process. However, some of these people need
to be oriented and trained in different steps of nutrition education programme. These
people are known as “change agents”. They are the agents of change because they
will carry out communication activities in their respective sectors and also train
other members of community. These agents, whether they are anganwadi worker,
health workers, teachers, agriculture promoters or other persons from a diversity of
sectors, must be very familiar with the message content, as well as, the techniques
to effectively communicate these messages. They must also be well informed of their
individual roles in the entire strategy. Therefore, training the “change agents” is
another vital stage during the implementation of nutrition education programme.
Since we want change agents to be effective educators, we should impart them a
training of good quality. We will now move on to the next aspect of training, that is,
training strategy.
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17.4.2 Training Strategy Nutrition Education
Communication
The purpose of the training strategy is to define the overall context for training, Programmes:
including who should be trained, what they should be trained in, when the training Implementation
should take place, etc. In many respects, this is the most important part of the training
process, since all future training decisions will be made within the overall context of
the strategy.
The training strategy should establish who will be trained such as programme implementers
(functionaries and supervisors), other influential people (physicians, pharmacists, NGO
personnel, traditional healers, small store owners, or local volunteers). It should establish
details about numbers to be trained, schedules and materials, and training of trainers
i.e. training other groups.
The trainer must specify and define the learning objectives clearly. The role of the
trainer is to help the trainees to learn that:
l they are learning something and are convinced that is useful,
l they practice what they are learning to do - more the practice the better it is,
l they receive feedback on their efforts and are rewarded when they do well, and
l rewards are from several sources and are as immediate as possible.
The training strategy should establish linkages between those who design messages,
products and communication materials, those who design and conduct training, and
those who implement the NEC, to make sure all groups promote the same messages.
Therefore, there should be some guidelines which need to be developed before the
training. Let us now move on to the training guidelines.
17.4.3 Training Guidelines

The training guidelines presented here are designed to train community workers to
improve nutrition in their area by learning in a practical way, the most important things
these needs to know and do. These are as follows:
1. The training should be directed to the performance of specific tasks - activities
needed to deal with the nutritional problems in the area.
2. To be fully effective, training requires maximum participation by the trainees
themselves.
3. As far as possible, the training should be given near the community in which a
trainee will be working later.
4. Training is not necessarily completed in a set period of time or at the end of
formal training course. Refresher training at regular intervals will increase the
effectiveness of community workers and supervisors.
After explaining training strategy and guidelines, we can now move on to formulating
a training plan. Let us learn how do we develop a training plan.
17.4.4 Plan for Training Programme

Although trainers may have the necessary knowledge about nutrition, they often do not
have enough knowledge about basic principles of training that can facilitate learning.
Therefore, it is recommended that, all trainers first should learn the basic principles of
training i.e how to conduct needs assessment, formulate a curriculum, select the
appropriate teaching method and plan a lesson. That is, they need to develop a plan
for training. There are different steps involved in formulating a training plan. These
steps are:
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Public Nutrition 1. Assessing learning needs
2. Defining learning objectives for the programme
3. Deciding on content area
4. Arranging contents
5. Selecting appropriate training methods
6. Selecting appropriate learning aid, and
7. Putting the entire schedule in a time frame
Let us review each of these steps very briefly:
1) Assessing learning needs

First step in planning a training programme is the assessment of learning needs of the
learner. We need to know what the target audience needs to know in order to perform
their role better and meet some specific requirements of the work they are involved
in. Thus, needs assessment helps us to know:
--- what is required of the role of the learner in the community,
--- what are the existing competencies, skills, knowledge already available with the
learner, and
--- what is expected of the learner by herself/himself, the community and organization.
Learning needs can be assessed by different methods such as: individual and group
meetings, interview, questionnaires, field observations in learner’s context of work and
by studying various documents like annual reports relating to the trainee’s work/
organization.
2) Defining learning objectives
After we have completed the needs assessment, we are ready to identify the objectives
for learning. These objectives will direct the entire plan for training programme and
affect the selection of content areas and teaching methods.
3) Deciding on content area
Content areas are derived from learning objectives. The content areas will include
actual topics and subject matter. They also include specific areas where we want
learners to gain knowledge, awareness and skills.
4) Arranging contents
After deciding on the content areas, we need to make a lesson plan. In the lesson plan,
the content areas should be arranged in such a way that there is a logical flow from
one content to another. This kind of arrangement helps to form linkages and ensures
faster learning without disrupting the chain of thought in the learners.
5) Selecting appropriate teaching method
We need to select an appropriate method for training the learners. The learning
process can be made easier with the help of different teaching methods and aids.
Selection of an appropriate method will depend upon the content areas whether we
want to give just the knowledge or impart skills. There are several methods of training
such as lecturing, assigning a task and imparting skills through practice. Let us review
these very briefly.
Lecturing is just one way of helping the trainees to learn. Lecture should build on what
the trainees already know, it should be made interesting by asking questions and posing
problems and asking trainees to suggest ways of solving them. Use visual aids whenever
394 possible.
Another way is by assigning a task that requires the students to do something or to Nutrition Education
observe a real life situation. The following Chinese proverb may be useful to remember Communication
Programmes:
in this context: Implementation
Hear and you forget
See and you remember
Do and you understand
Learners should also develop certain skills in a training programme. What are they? Let
us find out.
Teaching Skills to the learners- In nutritional care, community health workers have
to perform tasks such as weighing children to monitor their growth, identifying children
who are at risk of becoming malnourished, and advising mothers on how to feed young
children, identifying anaemic women or children and so on. Community health workers
need to learn three types of skill to do their job well. First, they must have manual
skills. For example, using their hands skillfully in weighing children. Second, they
would need thinking skills, for such tasks as identifying children at risk of becoming
malnourished. Finally, they would need communication skills: the ability to convince
mothers and other people to change their practices. Community health workers will
need a lot of practice in doing tasks before they develop the necessary confidence to
do those tasks independently. Communication involves a combination of decision-making
skills and reaching out to the group, including:
l Choosing objectives
l Deciding actual content of advice, i.e. what to say
l Deciding which learning aids to use
l Ability to speak clearly and sufficiently loud to be heard
l Ability to listen, ask questions, promote discussion.
l Use of non-verbal communication including gestures, eye contact, tone of voice
and posture to establish rapport, show concern and respect and encourage
responses.
The best way of training personnel in communication skills is: first, to demonstrate
good communication to the learners, and then let everyone in the training group practice
the skills with each other in role plays and discuss experiences. You can give the
trainees a checklist to judge how well the communication was carried out. After
everyone has had a chance to practice the communication skills, you can have a
general discussion to bring out the main points. You should encourage a friendly
atmosphere of helpful criticism and explain that we can only learn by making mistakes.
Communication can be made more effective through the use of appropriate learning
aids. Let us see how.
6) Selection of a appropriate learning aids
Learning aids can greatly improve our teaching, but only if they are well chosen and
properly used. A learning aid is only an aid to learning. Just showing a film, picture
or slide by itself will only have a limited effect. Rather than using them just for formal
one-way teaching, they should be used to stimulate understanding, discussion and
participatory learning.
Learning aids can:
l keep the group’s interest, arouse curiosity and hold attention,
l emphasize key points-when key headings are written out,
l allow step-by step explanation and sequencing of information,
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Public Nutrition l show something rather than just telling people- e.g. drawing of a life-cycle of a
disease, and
l provide a shared experience for discussion and questions.
An appropriate learning aid is:
l relevant to the learning objectives,
l affordable,
l easy to make and use,
l well understood by the audience,
l interesting and entertaining, and
l it also encourages participation and discussion.
Some factors to be considered in choosing the aids for a particular session are:
l Situation - To whom will the presentation be made: an individual or a group?
Where will the presentation take place - clinic, classroom or field?
l Subject matter and desired effect - What emotion is the communicator trying
to arouse - fear, surprise, shock? Does the information require gradual building-
up and linking with other information?
l Cost - Teaching aids cost money, and some are very expensive. Films, slide
projectors and overhead projectors are quite expensive. We should weigh
costs against benefits.
After we have developed a lesson plan and selected an appropriate training method
and learning aid, it is time to put the entire training plan into a time frame. Let us
see how we do that.
7) Putting the entire schedule into a time frame
We need to decide the time allocated to each content area and then determine total
time required to complete the entire training. Time also has to be allocated for short
and long breaks and for relaxation such as games etc. In case a field visit is planned,
time for traveling to and fro from the training venue should be planned accordingly.
So now our training plan is ready and we are ready to conduct the training for the
designated audience. After the training has been completed successfully, we would
like to know how much the trainees have gained in acquiring knowledge and skills.
For this, we conduct an assessment of training. Let us see how we conduct an
assessment.
17.4.5 Assessment of Training

Assessment enables trainers to know how much the trainees have learnt. It also
enables the trainers to know how they have performed as teachers. Most common
assessments usually have three components - theoretical, practical, and oral.
Assessment is usually done through an informal or formal testing. Let us study these
briefly.
a) Informal testing can be done inside the class or outside where the trainer can
check his/her own performance, and what trainees have learnt. A checklist for
such assessment is helpful, which covers objectives achieved, content and teaching
aids in training, participation by trainees and other aspects.
b) Formal testing or examination may be done in various ways:
l Practical tests - as an example of a practical test, trainees may be asked
to demonstrate how to weigh a child accurately and how to record the result
on a growth chart.
396
l Oral tests - the trainee’s knowledge of a subject is probed deeply by verbal Nutrition Education
questions and answers. Communication
Programmes:
l Written tests- the trainee’s knowledge is tested by writing answers to questions. Implementation
We have now accomplished an important aspect i.e. training for implementation of

nutrition education programme. After the training is completed, the educators need to
communicate the messages to the target population. Let us now learn how to execute
the message or the communication.
17.5 EXECUTING THE COMMUNICATION

INTERVENTIONS
Having trained the educators of the multidisciplinary team, we are now ready to
execute the communication activities with the target audience. We would review who
the target audience are and how do we reach them with our messages and materials.
Let us review the target audience first. We learnt in the earlier Unit 16, section 16.3
that target audience consists of three different types of groups. Just to recapitulate,
these groups are primary target, secondary target and tertiary target audience:
l The primary target audience consists of those whom the programme hopes will
actually perform the new nutrition and health practices.
l The secondary audience for the programme are those who influence the primary
audiences (for example, health care providers, family and friends and popular
public figures).
l The tertiary audience constitutes decision-makers, financial supporters, and other
influential people who can make the programme a success.
Thus, primary target audience will actually act and perform the new nutrition and
health behaviours. However, you would realize that all the members of a target audience
do not react in the same way after understanding the nutrition and health messages.
So, once the message has actually spread or diffused through a community, we need
to carefully analyze the answers to questions such as the following:
l Which individuals are most likely to initiate action of behaviour change
(innovators)?
l What motivates them?
l Who would be most likely to follow the innovators first? Why?
l Who is likely to resist any kind of change? What is preventing these individuals
from adopting a particular practice or course of action?
These questions bring out some important aspects we need to consider. In adopting a
practice, the following situations may arise:
i) A few members of primary target audience begin a new practice as promoted by
nutrition education communication programme. Such people are called innovators.
ii) Some other member follow in the foot steps of the innovators and adopt practice
as well. These are called early adopters.
iii) People who are hesitating in adopting the practice but have a favourable attitude.
They exercise caution and prefer to “Wait and Watch”. These are slow adopters.
iv) Then there are those people who resist change. They may be indifferent. On the
other hand, they may even be hostile. These are the people we would have to
tackle with tact and persuasion. The innovators and early adopters can help.
Thus during implementation of the programme, we would have to identify these groups
of people in our target audience and make special efforts to convince the slow adopters 397
Public Nutrition and also try to break down the barriers which exist in the case of those who reject
a message.
Having reviewed the target audience, let us review how do we communicate with
them through our messages and materials. Effective communication probably is the
basis of any NEC programme and effective communication depends to a great extent
on the choice and combination of media. You may recall studying in Unit 16, that no
one media can influence the change in behaviour of the people. We should always
make use of different media which will reinforce each other. It is important for us to
know that the programmes that have been successful in bringing about behaviour
change in nutrition, have demonstrated a need to complement the interpersonnel channel
with other media. There are several communication methods that can be used in a
NEC programme. These have been categorized under three approaches namely
individual, group and mass approaches about which we have already discussed in
Unit 16, section 16.5. They complement the types of media we studied in Unit 16. Let
us study about each one of these in detail.
There are several methods under the individual approach. A personal contact involves
face-to-face interview or counseling. This type of interpersonal communication is a
very efficient way of studying the nutritional problems and adapting the necessary
messages. Here the counselor/educator helps the target audience to find solution to
their problems themselves. When the time is limited and distances are long, then letter
or internet/telephone are effective methods. Individual approach provides first hand
information about nutrition related behaviours and develops good will and interest in the
target population.
Group approach is an effective communication method, when we want to address the
nutrition issues to a group of people such as adolescents, mothers of young children,
urban slum dwellers, etc. In the group approach, the educator/communicator should
know the interest of the group, leadership patterns and the type of group being
approached. The choice of message to be communicated must relate directly to them.
For example, pregnant mothers should have the discussion on issues related to pregnancy.
There are several methods of communication under group approach as discussed
earlier in Unit 16. Lecture cum demonstration has proved a favourite method of
keeping participants interested and in imparting information. Organizing discussion
meetings, so that target group is able to discuss their problems and find solution, are
another method of communication with the group. Role play and drama are more
participatory in nature and are based on the assumption that some situations cannot be
expressed just by talking and hence have to be dramatized.
Mass appraoch comprises the institutions and techniques by which specialized groups
employ technological devices such as press, radio, films etc to disseminate messages.
Mass media is more important in creating awareness and interest in new ideas among
general population groups.
We can simultaneously use all three approaches to bring about a change in behaviour
in the target population. For example, to promote exclusive breastfeeding for infants up
to 6 months, we can use mass media approach to generate awareness in the general
population. Simultaneously, we can use focus group discussions under group approach
where the mothers can be involved in understanding the reasons for exclusive
breastfeeding and developing positive attitude towards it. Interpersonal communication
can be used to address any specific problems faced by individual mothers and help
identify solutions to it. Thus, synergy between the three approaches would help in
bringing about changes in behaviours.
Having learnt about implementation of NEC, we will next discuss two main approaches
which have contributed to successful public health programmes. But first let us answer
the questions given in check your progress exercise and recapitulate what we have
398 learnt so far.
Nutrition Education
Check Your Progress Exercise 1 Communication
Programmes:
1. Why do we need a multidisciplinary team to produce support materials? Implementation
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a. Purpose of a training strategy
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b. Training guidelines
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..................................................................................................................
3. Answer the following briefly with examples:
a. What are the three types of skills needed by the community health workers
to do their job well?
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b. Different steps involved in planning a training programme.
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4. Enumerate the various communication methods that can be used in the community.
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There are many approaches which have demonstrated a successful delivery of a public
nutrition programme. We will now study two main approaches which have been used
to deliver successful public health programmes. These approaches are social marketing
and community participation. Let us start with social marketing first.
17.6 SOCIAL MARKETING: A KEY TO

SUCCESSFUL PUBLIC HEALTH
PROGRAMMES
In Unit 15, we briefly introduced you to the social marketing approach theory, under
theories of nutrition education. Social marketing has proven to be a very effective
approach in accomplishing the objectives of many public health programmes. In this
section, we will study in detail about the different aspects of social marketing approach.
We will learn what social marketing is, the difference between a social product and 399
Public Nutrition a commercial product and the marketing mix of social marketing process. Let us first
see what is social marketing.
17.6.1 What is Social Marketing ?

The term social marketing describes the application of marketing principles to the
design and management of social programmes. It is a strategic social change
management approach involving the design, implementation and control of culturally
acceptable programmes. Social marketing is a systematic approach to solving problems.
It is related to service utilization, product development and acceptance and behaviour
adoption. Since it is an approach and not a solution, there is no programme template
for others to copy. However, we can study an example, where social marketing
approach was used in a programme to improve child-feeding practices in Indonesia.
“A mother in Indonesia explained to the team that the reason she does not add
green leafy vegetables to her child’s rice is because the green leaves are difficult
for a baby to digest; she knows because when she tried, they made her baby’s
stool green. However, later, after being counseled by a doctor on the radio and
her local community health worker she feeds her child a mixed food with green
leaves. So, do 85% of the women in this province. By following this and other
advice related to improved child feeding, 40% of the children under 2 years
have significantly improved nutritional status.
This example shows that by using social marketing approach, women were able to
improve feeding behaviours related to child nutrition. You would be surprised to know
that since the introduction of social marketing two decades ago, the programmes using
this approach have continued to show good results. The programme example highlighted
above was selected as it illustrated a range of social marketing activities. Mass media
and individual counseling were combined to promote and educate about a product (a
home made infant food) for daily use.
Social marketing may involve both the selling of a commodity and the selling of an
idea or practice. Social marketing almost always begins with promotion of a health
related attitude or belief. The fundamentals of social marketing approach come from
marketing principles as follows:
l the focus is on consumer needs.
l programme organization and management may be structured to reflect a marketing
operation. For example, health workers’ job descriptions and their training are
restructured so they become better sales agents for the programme, not just
deliverers of the services.
l commercial avenues are sought for products traditionally kept in the health and
nutrition sector.
l the result orientation of marketing implies that progress towards achieving goals
is constantly measured.
However, there is a difference between a social product and a commercial product.
Let us find out the difference between the two products.
17.6.2 Social Products and Commercial Product

You must be wondering if there is a difference between a socially beneficial product
or commercial product. Yes, there is a difference between the two. The difference
is listed as follows:
l Social products are often more complex to use than commercial ones
l They are often more controversial
400 l Their benefits are often less immediate
l Distribution channels for social products are harder to utilize and control Nutrition Education
Communication
l The market for social product is difficult to analyze Programmes:
Implementation
l Audience for social products often have very limited resources
l The measure of successful “sales” or adoption of social products is more stringent
than for commercial ones
The extra challenges mean that the research and the planning stages of a social
marketing effort must be particularly sound. Before we plan any programme, using a
social marketing approach, we will have to understand marketing mix of a social
marketing process. Let us understand the marketing mix concept.
17.6.3 The Marketing Mix of Social Marketing Process

Social Marketing conceives of the consumer as the center of a process involving four
variables: product, price, place, and promotion. A successful programme is organized
around a careful analysis of each of these variable and strategy, including how they
will interact.
A proposed Product (whether a commodity, idea, or health practice) must be defined
in terms of the users’ beliefs, practices, and values.
Price can refer to a monetary expenditure, an opportunity cost, a status loss, or a
consumers’ time. The fact that a rural woman pays no money to get her child the
vitamin A dose at the health centre doesn’t mean that it costs her nothing. The
day of travel, the inconvenience to family, or the risk of side effects may seem
too costly relative to perceived benefits. The price of a particular product is never
fixed, it varies according to the target audience segment, and often according to
the individual.
The concept of Place refers to the channels through which products flow to users
and the points at which they are offered. Product availability and distribution may
involve not only retail and wholesale supply system, but also the efforts of health
providers, volunteer workers, friends and neighbours.
“Place” may be a store, a health center, an anganwadi or even a person such as a
traditional birth attendant who carries a supply of ORS.
In any social marketing activity, Promotion requires more than simple advertising. It
requires extensive consumer education to assure appropriate use of products. Motivational
strategies are also essential in encouraging adoption of new ideas and social products.
Figure 17.1 depicts the marketing mix in the process of social marketing and shows
consumer (audience) being the center of the process.
PRODUCT
PRICE AUDIENCE
AUDIENCE PLACE
PROMOTION
Figure 17.1: Process of social marketing

401
Public Nutrition Thus, using these 4 ‘Ps’ of social marketing, we can use the social marketing
approach to promote positive health and nutrition behaviours. How do we do that? Let
us find out.
In order to know how social marketing can promote positive nutrition and health
behaviours, we will focus on four aspects: two purposes and two techniques. These
aspects distinguish social marketing from other health education efforts. Let us first
look at the two purposes.
1. The first purpose of social marketing is to bring about a change in behaviour and
not just imparting information. Social marketers have their eye on what it will take
to get people to try something new, whether it is going to the health center or
cooking green leafy vegetable every day for the children. When it comes to
promotional education, unless the information is relevant to changing the behaviour,
it is not included.
2. The second purpose of social marketing is demand creation. Social marketing
concentrates on half of the marketing equations that is often ignored - creation
of demand. Far too often, we think only of supply, building health clinics, producing
nutritious infant foods etc. but often the health clinics are empty and infant foods
not bought. Demand has not been realized because we have not understood
consumer needs and desires and catered to them. We are only beginning to
recognize and learn how to find out what consumers look for in health services
or seek in an infant food, and how to adapt our service and products for them.
When we do this, we make programmes more cost effective.
Having learnt about the purpose of social marketing, now let us look at the two
techniques basic to social marketing:
a. Social marketing uses formative research technique to understand consumer
demand. We have already studied about it in the previous unit. In promoting
behaviour changes and in creating demand, social marketing uses, as social
marketing expert, Dick Manoff has called it, a feed forward approach that
minimizes “feed back shocks”, or as others would call it, formative research. That
is we go in the community to consumers, to find out what they want. This helps
us to shape our products and fine tune the promotional angle. For example, breast
milk can be promoted, as the best food for young babies and as protective since
it has antibodies. However, our most motivational appeal to mothers may be that
it is a convenience food, as it does not require any cooking, if convenience is what
mothers want.
b. Finally, social marketing requires creativity, not just in message design where
persuasive, captivating and memorable messages are the goal, but also implementing
qualitative research free of researcher bias, and in developing programme strategies
through creative interpretation of research findings. Too often we find that good
research has been done but has been poorly implemented for programme needs.
Thus, we learnt how we can use social marketing approach in promoting positive
health and nutrition behaviours. Let us now move on to the second successful approach
i.e. community participation.
17.7 COMMUNITY PARTICIPATION

What is ‘Community’? A community is referred to as stable, small, autonomous
and self contained unit such as colonies of pioneer settlers, primitive tribes,
villages and immigrant areas. The same term has also been used for towns and
cities. Whatever be the size of complexity of a community, it has certain characteristics.
These include occupation of a territorial area, common interests, common pattern of
social and economic relations, common bond of solidarity, network of social institutions
402 and some degree of group control. Community means more than just people who live
together; it implies sharing and working together in some way.
When people live together in a community, they may have certain problems which they Nutrition Education
might want to solve together. Before problems can be solved, the community members Communication
Programmes:
must first understand all the factors involved. This will help them to make decisions Implementation
about solving these problems. This brings us to the term community participation (CP).
Community participation means adopting a ‘bottom-up’ approach where members of
the community make the decision rather than ‘top-down’ approach where the decisions
are made by senior persons in health services - the so called ‘experts’. Participation
by a community may vary in degree depending upon the extent of their participation.
We will now discuss various aspects of community participation. These are spectrum
of community participation, types of community groups, the process of dialogue in
community participation and benefits of community participation.
Let us discuss each of these in detail. We will begin with spectrum of community
participation.
17.7.1 Spectrum of Community Participation

The American planner Sherry Arnstein suggested that there is a continuum of
participation. Figure 17.2 shows simplified version of Arnstein’s ladder of participation.
At one extreme, there are actions that are really forms of manipulation. Manipulation
means controlling people like puppets even though we pretend to let them make
decision. At the opposite extreme, there is total participation or complete control of
its affairs by the community.
Decision taken by outsiders’: community but

Manipulation with the impression they are involved in
decision-making
Consultation Opinion of community sought but decision left
to outsiders
Community control Complete power to make decisions given to
 community
Figure 17.2: Simplified version of Arnstein’s ladder of participation
You must be wondering as to why do we need a community approach? An important

justification for community participation is the need to shift the emphasis from the
individual to the community. Many influences on behaviour are at the community
level and not under the control of individuals. This includes social pressure from other
people, norms, culture and the local socio economic situation. There are many types
of groups formed in a community. These groups can facilitate implementation of
programme interventions. Let us find out about these groups.
17.7.2 Types of Community Groups

Before we learn about different types of community groups, let us first understand why
do we form community groups, why don’t we just work with individual members of
a community? We want to form community groups because forming community
groups helps community members agree on common problems and recognize that
they can solve these problems by themselves, with external help as required.
There are different types of community groups which can be formed in a community.
These are:
a. Self help groups - run by people for their own benefits.
b. Representative groups - elected and answerable to the community.
c. Pressure groups - a group of self appointed citizens taking action on what they
see to be the interest of the whole community.
403
Public Nutrition d. Traditional organizations - well established groups, usually meeting the needs
of a particular section of a community (mothers’ union, parent-teachers’
association).
e. Social groups - exists mainly to organize a social event e.g. music group, sports
club etc.
f. Welfare group - exists to improve welfare for others e.g. operating feeding
programme.
Thus, we can identify these groups in the community and seek their support in
implementation of nutrition education communication programmes. You would also
realize that community participation is a very slow and gradual process. To begin this
process, the field worker has to visit the community groups, establish a rapport with
them and initiate dialogue to invite their participation. Let us now look at the process
of dialogue in community participation.
17.7.3 The Process of Dialogue in Community Participation

The technique of carrying out a dialogue with the community depends upon the skills
of the field worker. You will note from the Figure 17.3, how the field worker initiates
a dialogue asking their needs and gradually makes the community aware of other
needs. For example, health and nutrition may not be the felt need of the community
in the beginning, but the field worker can make them aware of these needs gradually.
The Field Worker The Community Response
Ask the community about its problems

and needs 
Community explains its needs

Ask questions to find out basis of needs
 Community explains basis of its
Challenge it to consider wider issues needs

and provide educational inputs
 Community acquires awareness

of other issues and begins to
consider alternate needs
Figure 17.3: Process of dialogue in community participation
Why do we want to involve community in our programme? What are the benefits of
community participation? Let us now study these aspects.
17.7.4 Benefits of Community Participation
What are the benefits of community participation? Community participation helps
the members of the community to collectively seek solutions to their problems. It
gives them a sense of ownership for their community and helps them to pool
their resources to help solve their common problems. Some of the benefits of
community participation are that it:
l encourages cooperation with other people and enables them to accomplish things
which they would not be able to do alone,
l provides contact with other people so that members can increase their knowledge
and experience,
l helps develop the skills and talents of individual members,
404
l makes programme relevant to local situation, Nutrition Education
Communication
l ensures community motivation and support, Programmes:
Implementation
l improves utilization of services,
l promotes self help and self reliance,
l improves communication between health worker and community, and
l enables the development of primary health care.
Thus, we learnt that there are several benefits of community participation. That is why
many public health programmes have been able to accomplish their objectives by
involving community during planning and implementing process.
A very good example of the importance of social marketing and community participation
comes from the USAID sponsored “Social Marketing of Vitamin A-Rich Foods Project”
carried out in Thailand over a period of three years. This project showed:
a. Significant improvement in knowledge, attitude, and practices in the intervention
area.
b. Substantial improvement in the vitamin A and nutritional status of the target
population, and
c. The sustainability potential of such interventions which was reflected in the behaviour
of local government officials integrating food and nutrition activities into routine
work and personal schedules.
Community participation leads to a better relationship between the community and the
health worker. Instead of a servant-master relationship, there is trust and partnership.
It has been proven that the programmes that have adequate participation by community
are sustained compared to those which have no or inadequate community participation.
In addition to the two approaches discussed above, public health programmes have also
sought participation of school children in promoting health and nutrition messages.
School children have been instrumental in changing behaviours, because they are
enthusiastic, curious, open to new information and willingness to learn. School children
can influence the behaviours of following community groups:
--- Younger children
--- Children of the same age groups, and
--- Family and community
Thus we learnt how we can use different approaches during the implementation of
nutrition education programme and bring about a change in behaviours of target
population. Hope geared with this knowledge you are better equipped now or bung
about a change in behaviour of target population. Let us take a break here and refresh
our understanding of the topics discussed above.
1. Explain these terms briefly.
a. Social Marketing
..........................................................................................................................
..........................................................................................................................
b. Community Participation
..........................................................................................................................
..........................................................................................................................
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Public Nutrition
2. What are the four Ps of Social Marketing process?
..........................................................................................................................
..........................................................................................................................
3. Match the following:
Column A Column B
a) Self help groups i) a group of self appointed citizens
taking action on what they see to
be the interest of the whole
community
b) Pressure groups ii) run by people for their own benefits
c) Social groups iii) exists to improve welfare for
others- e.g. run feeding program.
d) Welfare group iv) elected and answerable to the
community
e) Traditional organizations v) exists mainly to organize a social
event - e.g. music group, sports
club etc.
f) Representative groups vi) well established groups, usually
meeting the needs of a particular
section of a community
17.8 LET US SUM UP

In this unit we learnt that there are three main aspects of implementation process.
These are production of support materials, training and executing communication
interventions. Production of support materials requires need for a disciplinary team and
pretesting before they can be produced in large scale. Training is a very major aspect
of implementation. We studied about how to design and conduct a training programme.
Designing and conducting an effective training programme involves developing a training
strategy, developing training guidelines and a plan for training programme. We also
learnt about the various steps of a training plan which are assessing learning needs,
defining learning objectives for the programme, deciding on content area, arranging
content, selecting appropriate training methods, selecting appropriate learning aid and
putting the schedule in a time frame. We also discussed many communication methods
which can be used by the educators to disseminate messages to the target population.
We concluded the unit by studying two approaches, that is, social marketing and
community participation that have proven to be very effective in delivering successful
public health programmes.
17.9 GLOSSARY
Commercial venues : places involved in producing, transporting, or merchandising
a commodity.
Innovative approach: an approach characterized by new things or new ideas.
Traditional healers : healing done by application of knowledge, skills, and practices
based on the experiences indigenous to different cultures.
These services are directed towards the maintenance of
health, as well as, the prevention, diagnosis, and improvement
of physical and mental illness. Examples of traditional health
service providers include herbalists, faith healers, and
406 practitioners of Chinese or Ayurvedic medicine.
Nutrition Education
17.10 ANSWERS TO CHECK YOUR PROGRESS Communication
Programmes:
EXERCISES Implementation
1. We need a multidisciplinary team to produce materials because it is very rare to
see any one professional having the knowledge and the skills to develop
communication materials. We need a team consisting of the nutritionist, creative
or graphic artist, technicians and the overall coordinator.
2. a. The purpose of the Training Strategy is to define the overall context for
training, including who should be trained, what they should be trained in,
when the training should take place, etc.
b. The training guidelines designed to train a community worker in a practical
way are direct the training to the performance of specific tasks, training
should ensure maximum participation by the trainees themselves. The training
should be given near the community in which a trainee will be working later,
and refresher training at regular intervals to increase the effectiveness of
community workers, and supervisors.
3. a. These skills are: manual skills - for example, using their hands skillfully in
weighing children, thinking skills - for such tasks as identifying children at
risk of becoming malnourished, and communication skills - the ability to
convince mothers and other people to change their practices.
b. Different steps involved in planning a training programme are: assessing
learning needs, defining learning objectives for the programme, deciding on
content area, arranging contents, selecting appropriate training methods,
selecting appropriate learning aid, and putting the entire schedule in a time
frame.
4. Methods of communication intervention used in the community are:
Individual approach; which involves dealing with individuals on a one to one
basis. It can involve face to face interview, counseling and sending letters.
Group approach, is an effective communication method, when we want to
address the nutrition issues to a group of people such as adolescents, mothers of
young children and urban slum dwellers, etc. Lecture cum demonstration,
organising discussion meetings, role play and drama are some of the group
approaches that can be used.
Mass approach, the institutions and techniques by which specialized
groups employ technological devices such as press radio, films etc., to disseminate
messages.
1. a. Social Marketing is a systematic approach to solving problems, it is related
to service utilization, product development and acceptance, and behaviour
adoption. Social marketing may involve both the selling of a commodity and
the selling of an idea or practice.
b. Community participation means adopting a ‘bottom-up’ approach where

members of the community make the decision rather than ‘top-down’
approach where the decisions are made by senior persons in health services
- the so called ‘experts’.
2. Social marketing conceives of the consumer as the center of a process involving
four variables: product, price, place, and promotion.
3. a --- ii, b --- i, c --- v, d --- iii, e --- iv, f --- iv. 407
Public Nutrition
UNIT 18 NUTRITION EDUCATION
PROGRAMME: EVALUATION
Structure
18.1 Introduction
18.2 Evaluation - Basic Concept
18.3 Purpose of Evaluation of NEC Programme
18.4 Developing an Evaluation System for NEC Programme
18.4.1 Integrating Evaluation into Programme Planning
18.4.2 Input Evaluation: Evaluating During Intervention
18.5 Types of Evaluation

18.5.1 Process Evaluation
18.5.2 Summative Evaluation
18.5.3 Formative Evaluation
18.6 Major Features of Evaluation
18.7 Conducting a Dynamic and Participatory Evaluation
18.8 Contribution of Nutrition Education Programme to Changes in Behaviour
18.9 Let Us Sum Up
18.10 Glossary
18.1 INTRODUCTION
So far so good. Our NEC car has been on the road for several months now and has
gathered several months of experience in implementation. It is time to evaluate the
journey and answer questions like “are we taking the NEC car towards its
destination, the planned objectives? Could the journey of implementation been shorter,
easier, less expensive? What have we learnt, so that we can plan a better journey
next time?”
In fact, the time to evaluate is not at the end of the programme, but evaluation should
be integrated in the whole process from start to finish, and must necessarily assess the
effect of all types of interventions in a nutrition education communication strategy. In
this unit, we will discuss the concept and purpose of evaluation and different types of
evaluation. How to develop an evaluation system ? What are the major features of
an evaluation system? How to conduct dynamic and participatory evaluation of a NEC
programme. These are the major aspects covered in this unit.
Objectives
After studying this unit you will be able to:
l explain the concept and purpose of evaluation,
l elaborate on different features of evaluation,
l describe different types of evaluation, and
l develop skills to conduct an evaluation.
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Nutrition Education
18.2 EVALUATION-BASIC CONCEPT Programme:
Evaluation
In Unit 14, section 14.4, we briefly introduced you to the concept of evaluation as one
of the steps in the management of public nutrition programmes. In this section, we will
explain the concept of “evaluation” in greater detail especially in relation to nutrition
education programmes. You already know what evaluation is? Very simply stated
evaluation means “to judge the value of something”. Before we go further, let us
first understand evaluation through scientific definitions given by many experts. Although
evaluation has been defined in various ways, presented herewith are two of the most
appropriate definitions in this context.
1) “Evaluation is a systematic and scientific process, determining the extent to which
an action or set of actions were successful in the achievement of pre-determined
objectives. It involves measurement of adequacy, effectiveness and efficiency of
health services”.
2) ‘‘Evaluation is also defined as the systematic application of social research
procedures for assessing the conceptualization, design, implementation, and utility
of intervention programmes’’.
You may note here that both the definitions stress the importance of planning the
evaluation at the same time as the programme is planned and implemented. It is too
late to think of evaluation at the end of programme implementation. You may recall that
in Unit 14, section 14.4, we discussed about eight stage model of planning evaluation.
This is the model which can be used in nutrition education programme also. Thus
evaluation is an integral part of programme planning and management, whether it is
a training/education programme, a specific nutrition intervention, development activities,
or education of the public.
Further, you may have made note of the following two terms - effectiveness and
efficiency -used in the definitions above. These terms are used very frequently in
evaluation. Let us understand what they mean:
l Effectiveness – It means whether or not a programme achieves its stated
objectives, i.e. did it work?
l Efficiency – It means the amount of effort in terms of time, manpower, resources
and money required to reach the objectives-was it worth the effort?
In simple terms, therefore, evaluation is a process which helps us to know whether
the programme we planned/implemented worked or not and was it worth the
effort or not.
Having understood the concept of evaluation, we come to the next important
aspect of evaluation as to why do we do evaluation. Let us study the purpose of
evaluation next.
18.3 THE PURPOSE OF EVALUATION OF NEC

PROGRAMME
Although we briefly discussed the purpose of evaluation in Unit 14, section 14.5, we
will recapitulate it here. Evaluation is conducted because programme managers and
planners must distinguish useful current programmes from ineffective and inefficient
ones. They should also plan, design, and implement new efforts that effectively and
efficiently have the desired impact on the target group. In order to do all this, they
must obtain answers to a range of questions, such as:
l Is the strategy based on priorities from a broad analysis of the nutrition situation,
needs assessment and cultural and behavioural aspects?
409
Public Nutrition l Are the interventions selected likely to reduce significantly the nutrition problems?
l Is the most appropriate target population selected?
l Will the various interventions reinforce, or counteract each other?
l Is the intervention being implemented in the ways envisioned?
l Is it effective?
l How much does it cost?
l If the nutrition education programme is one of several interventions, how can its
effect or impact be separated from the impact of other interventions?
Therefore, we evaluate to answer the above questions. We evaluate to aid future
planning and to improve programmes, to increase our understanding of nutrition education
practice and finally to add to the body of knowledge upon which our work is based.
Thus, we evaluate for the following reasons:
l Firstly, to achieve operational efficiency and to study the effects of nutrition
education practice so that we can feed our findings back into practice and
improve it.
l Secondly, to obtain data that permit interpretation of programme effectiveness so
as to obtain administrative support, community support and donor support. One
reason why there is widespread skepticism regarding the cost-effectiveness and
impact of NEC is that such programmes have been poorly evaluated.
l Thirdly, to strengthen the scientific basis of practice of nutrition education and
communication.
Box 1 highlights the reasons for evaluating nutrition education programmes.
Box 1 Reasons for Evaluating Nutrition Education Programmes

To assess:
l impact or effect,
l how programmes are planned and executed,
l how programme personnel perform,
l how effectiveness can be improved,
l the utility of a programme, and
l to satisfy the programme sponsors
Thus, you would note here that evaluation is done to assess whether or not changes
have taken place as a result of the programme activities. Evaluation should show
whether :
l The change took place or not
l If the change took place, then did it happen as a result of the programme, and
l The amount of effort required to produce the change was worthwhile.
You would realize that evaluating NEC programme involves making some important
decisions. For example, What changes should you measure? How should you measure
those changes? How can you prove that the changes took place as a result of the
programme, including knowledge and behaviour changes? All these decisions should
410 be related to the objectives of the programme.
For evaluation, we have to develop an appropriate evaluation system into our programme, Nutrition Education
so that we can conduct evaluation in a systematic and scientific way. Let us now find Programme:
Evaluation
out about developing an evaluation system.
18.4 DEVELOPING AN EVALUATION SYSTEM FOR

NEC PROGRAMME
You might recall reading in Unit 15, section 15.5, that during the conceptualization
phase of NEC programme, the last step listed under the key elements of intervention
strategy, was “evaluation”. So the plan for evaluation was already conceptualized
before formulation and implementation of the NEC programme. Thus, you now realize
that evaluation should be built into all phases of programme planning, implementation,
and management right from the conceptual stage. There are two main aspects which
we need to keep in mind while developing an evaluation system:
l Firstly - Goals and objectives of the programme should be linked to

evaluation. You may recall reading about setting of objectives of a NEC programme
in Unit 16, Section 16.2. They should be elaborated in such a way that we are
able to assess whether a change has occurred or not at the end of the programme.
We need to integrate evaluation into programme planning.
l Secondly, we should also justify the use of resources or inputs i.e. men, material
money etc. through an evaluation process. We need to conduct evaluation of
inputs used during the intervention process.
Thus, we will look at these two aspects i.e integrating evaluation into programme
planning and input evaluation briefly. Let us first study how we can integrate evaluation
into programme planning.
18.4.1 Integrating Evaluation into Programme Planning

Goals and objectives of a nutrition education programme that, we studied earlier, are
identified through assessment of the existing nutrition situation, an analysis of the
problems which can be solved by nutrition education, a description of the various actors
and target groups and a list of the systems that can support nutrition education activities.
Goals and objectives for nutrition education programmes are all based on the assumption
that there is room for improvement and that nutrition education is the right strategy to
be used. Specification of goals and objectives is very important, both for an
education programme itself, and for the evaluation. For the programme they give
direction, expected results and time frames, and for the evaluation, they give criteria
for measurements. Programmes often suffer from poorly developed objectives, which
also make evaluation difficult.
You may recall reading earlier in Unit 17 that objectives can be classified as
nutritional, educational or communication in nature, whatever be the objectives, it
is important to note, that objectives must be formulated precisely, specifying expected
outcome(s) and how, where, and under what conditions results will be achieved. For
educational programmes, the following elements of an objective are suggested: An
objective should contain:
l the expected change - outcome (e.g. behavioural, nutritional status),
l the conditions under which the expected change is to take place, including,
for example, the geographical area, time, target group and activities used, and
l the criterion, or the extent of the expected change that will satisfy the
objective. In other words, comparing change with the norms or standards or
expectations laid out for the programme.
411
Public Nutrition To illustrate, an objective could state that the proportion of mothers exclusively
breastfeeding their children for first six months of age will increase from 16% to 20%
in two years in x district as a result of NEC activities.
Sometimes we also need to evaluate certain factors affecting the implementation
process. These are known as contextual factors. It is important to analyze contextual
factors that may not have been directly addressed in the objectives but that have a
bearing on implementation. These factors include the religion, race and ethnic
background and sex of the target group in the community, and general socio-economic
and political issues. Such an evaluation is known as contextual evaluation and can
focus on factors that may impede a programme, thereby, enabling the researcher to
plan strategies to cope with them.
Let us study the other aspect - evaluating inputs used in the implementation of the
programme.
18.4.2 Input Evaluation: Evaluating During Intervention

Input evaluation takes a critical look at the adequacy and appropriateness of the
resources being used to carry out the programme. A programme can be said to have
at least four types of inputs. These are:
--- the programme plan,
--- the material resources, and
--- human resources such as programme staff; and time, particularly that allocated
for the initial phase, evaluation, feedback, and follow-up.
Many evaluations of otherwise well-designed programmes show that programme
planners consistently under-estimate time and effort needed to adopt a new practice.
NEC programmes, which are conceptualized and formulated well may fail at the
implementation level. Hence, continuous monitoring is essential. In fact, evaluation can
be planned at various levels. We studied earlier that it is ideal to plan evaluation of
NEC from the conceptualization phase and thus causal analysis and formative research
form part of an evaluation. Evaluation can also be undertaken during the phase of
formulation. Since during this phase there is still time to reflect, not only on the
relevance of intervention but also on the order in which activities should develop. We
can measure the knowledge, attitudes and practices of the target population before the
intervention to provide a basis for comparison afterwards. You will be surprised to
know that you do not have to wait until the end of NEC programme to conduct
evaluation, we can do an evaluation even during the implementation phase since there
are lessons to be learnt from the experience. We will learn more on this topic in the
next section. Here, let us now test our knowledge about what we have learnt so far.
1. What do you mean by evaluation?
........................................................................................................................
........................................................................................................................
2. “Evaluation is an integrated part of programme planning and management”
Do your agree with this statement?
Yes No
Give reasons for your answer.
.........................................................................................................................
.........................................................................................................................
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Nutrition Education
3. Why do we need to evaluate a nutrition education programme?
Programme:
......................................................................................................................... Evaluation
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
4. What are the major aspects you need to keep in mind while developing an
evaluation system?
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
Having learnt about the concept of evaluation and how to develop an evaluation
system, we come to the next issue, that is, how to carry out the evaluation process.
Can we conduct different types of evaluation, which would be an evaluation for a
change in outcomes, processes and or inputs? In the next section, we will study about
these aspects.
18.5 TYPES OF EVALUATION

There are different types of evaluation conducted in a programme. You can choose
the type of evaluation for your programme based upon the purpose/objective of the
evaluation and the questions you want to answer. For example, you may want to know
whether the expected change in objectives/outcome has occurred or not. You may also
want to analyze and document the entire process of implementation, review critically
and learn lessons from it. There are different types of evaluation you can adopt. Let
us learn about these different types of evaluation. Primarily, evaluation can be
classified as:
--- Process evaluation
--- Summative evaluation
--- Formative evaluation.
We will study about these briefly now. Let us start with process evaluation.
18.5.1 Process Evaluation
Process evaluation, as the name suggests, is a tool for monitoring progress. The
major emphasis in process evaluation is on documenting and analyzing the way the
programme works in practice, to identify and understand important influences on its
operation and achievements. The primary purpose is to improve understanding of how
a programme achieves what it does. It indicates whether the strategies and activities
being implemented are likely to generate the expected results. Process evaluation also
indicates whether the work is done on time. If the activities do not meet expectations,
they may be changed or even stopped. It is much better to change a programme during
implementation than await a retrospective analysis to find out where it went wrong and
who was responsible for the failure - when it is too late. Examples of processes which
could be evaluated would be community mobilization, women’s group formed, review
meetings held with counterparts etc.
There are several factors which should be considered while planning a process
evaluation. These factors are: objectives, target population, strategies and activities,
scheduling, and resources used in the programme. For NEC programmes in particular, 413
Public Nutrition the behavioural objectives, primary and secondary audience groups and the types of
communication strategies being used will be important considerations.
Process evaluation results have a number of uses, depending on the purpose of the
evaluation, at what stage of development the programme is, and the funding agency.
An important function of process evaluation is to provide information about the
congruence between programme design and implementation. The results should,
therefore, be fed back to project managers and staff on a continual basis. A plan for
use and dissemination of process evaluation findings should be made when planning
the evaluation system. It is important to present the findings in ways which correspond
to the needs and competencies of the relevant stakeholders. Having looked at the
process evaluation, let us look at the other type of evaluation i.e. summative evaluation.
18.5.2 Summative Evaluation

Summative evaluation is the systematic use of research techniques to measure
outcomes and overall programme effectiveness. For example, it is not enough to
know that radio programmes were broadcasted, products distributed, health workers
trained, or even that programmes were listened to, understood and acted upon. The
ultimate goal is not people hearing advice but taking it, changing their behaviour and
ultimately improving their own and their children’s health and nutrition as a result of
the advice.
Summative evaluation examines questions such as: Did the programmes achieve its
explicitly stated goal? What was the magnitude of the programmes impact? What
were the unexpected outcomes? What parts of the programme were most, or least,
successful? An example of summative evaluation would be - proportion of pregnant
women who started consuming 100 iron folic acid tablets increased from 20% at base
line level to 25% percent at the end of the programme in 2 years. In addition to this,
summative evaluation would also examine other issues as stated above e.g. did the
women have problems accessing the tablets. Did they complain of side effects? etc.
A useful evaluation looks at the process of the intervention’s effects, as well as,
measuring its overall impact. In order for a final health status outcome to be achieved,
a series of interim steps must be successfully completed. The evaluation of these steps
includes investigating whether:
l the target population had access to the channels of communication used by the
programme,
l the messages actually reached the population through those channels,
l the content of the messages was learned and retained by the audience,
l members of the target audience actually changed their behaviours in response to
the programme, and
l the nutritional status of the target groups improved as a result of these changes
in behaviour.
Thus you may have realized that summative evaluation uses techniques to measure
outcome and also overall programme effectiveness.
The third and the last type of evaluation is formative evaluation. Let us study this
briefly.
18.5.3 Formative Evaluation

Formative evaluation is done to monitor the progress during the programme
implementation. Formative evaluation, as the name suggests, typically involves gathering
information during the early stages of your project or programme, with a focus on
finding out whether your efforts are unfolding as planned, uncovering any obstacles,
414
barriers or unexpected opportunities that may have emerged and identifying mid-course Nutrition Education
adjustments and corrections which can help insure the success of your work. Programme:
Evaluation
Essentially, formative evaluation is a structured way to provide programme staff with
additional feedback about their work. This feedback is primarily designed to fine tune
the implementation of the programme, and often includes information that is purely for
internal use by programme managers. An example of formative evaluation would be
that, a radio programme on nutrition may be evaluated to get a feedback on how well
it is received by the target audience. Planners and implementers then use the assessment
to improve further on it. Formative evaluation can be informal or formal.
As elaborated by Robert Stakes ‘‘When the cook tastes the soup, that’s formative;
when the guests taste the soup, that’s summative.” Isn’t that interesting. Programme
planners may choose to incorporate any type of evaluation in the evaluation plan.
You have looked at different types of evaluation and you have also learnt how to
develop an evaluation system. Let us now learn about major features of evaluation.
18.6 MAJOR FEATURES OF EVALUATION

You know that it is important for the evaluator to know what they want to evaluate
and how they want to evaluate. The evaluator’s challenge is thus twofold. It is to
determine:
a) Exactly what questions to be asked during evaluation i.e. determining evaluation

questions, and
b) The strategy and methods to employ for answering these questions i.e. selecting
evaluating strategy and methods
These now become the main features of the evaluation because the entire evaluation
process will center around these two issues. Let us review these features in detail.
a) Determining evaluation questions

The evaluator’s first task is to work with project planners and implementers to understand
the explicitly stated, measurable objectives of the programme. We gave you examples
of several questions earlier when we discussed purpose of evaluation. The questions
are established at the programmes onset, and most likely include desired level of
exposure to messages, knowledge of information, first trials of new practices, adoption
of behaviour, and impact on nutritional status, morbidity and mortality. In addition,
however, the evaluator must consider other issues mentioned as follows:
l the relative importance to project planners of different measurable goals.

For example- Is the primary goal a change in practice or nutritional status?
l characteristics of the target audience and the importance of its different

subgroups. For example, Were these groups more likely to learn or change or not?
l expectations: For example are people expected to change immediately in response

to the intervention or the change will be gradual? Is the change expected to be
short term or permanent?
l expectations regarding changes in the health delivery system itself, for example,
delivery and quality of nutritional services.
Further the evaluator must take into consideration the needs of users of evaluation
findings. For example, do the users primarily want to know about the impact of the
intervention, or about various process indicators? Do they have questions regarding
cost effectiveness and administrative efficiency?
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Public Nutrition Not all significant questions can be answered in a summative evaluation. The evaluation
process is one which continues selection among alternatives, and can carefully determine
priorities in terms of audiences, funds, and time constraints.
Thus the evaluator should prepare a list of questions for which he seeks an answer
during an evaluation, keeping in view various issues discussed earlier. Now the evaluator
has to know what strategy and methods to use to get the answer of these questions.
Let us look at the strategy now.
b) Selecting evaluation strategies to answer the questions

Once the list of appropriate questions has been selected, the evaluator must determine
which methods of data collection and analysis are appropriate for seeking answers.
No one model, approach or methodology will be successful in every programme.
An effective evaluation strategy should incorporate a number of different methodologies.
Distinct questions are often best answered through different designs. Distinct designs,
which present alternative ways of approaching the same question, can provide particularly
strong evidence of programme impact if their results are consistent.
Several research tools can be used in evaluations of communication interventions.
Few examples include:
l Large-scale survey conducted both before and after the intervention to measure
impact regarding a group’s knowledge, attitudes, and practices relating to the
target nutrition problem. The “after” survey should determine access and exposure
to mass media channels, messages and so on. Ideally, a group or cohort of
individuals is surveyed several times to measure progress in the intervention.
These surveys most commonly employ quantitative methods of data collection.
l Demographic data (including socioeconomic status, age, literacy and education)
help determine whether changes in practice occur only for certain groups of
people.
l Observational studies are useful to test the validity of self-reported data.
l Qualitative research tools such as focus group discussions, semi-structured
interviews and various participatory methods.
Next thing, which comes to our mind, is that which method should we use in the
evaluation process. There are two types of methods which can be used in an evaluation
strategy. These are quantative and qualitative methods. Let us learn about these
briefly
c) Quantitative methods and Qualitative methods
Quantitative methods are research methods concerned with numbers and anything
that is quantifiable. They are therefore to be distinguished from qualitative methods.
Counting and measuring are common forms of quantitative methods. The result of the
research is a number, or a series of numbers. These are often presented in tables,
graphs or other forms of statistics.
Qualitative methods involve methods of data collection and analysis which are non
quantitative.
These methods are designed to help researchers understand people and the social and
cultural contexts within which they live. Qualitative data also helps to understand and
complement the quantitative data. Qualitative data sources include observation and
participant observation (fieldwork), interviews and questionnaires, documents and texts,
and the researcher’s impressions and reactions.
Having understood the meanings of quantitative and qualitative methods, the critical
issue which arises is fitting both the methods to the purpose of the evaluation. The
416 use of both qualitative and quantitative, and multiple methods, can strengthen the
validity of findings, if results produced by different methods are congruent and/or Nutrition Education
complement each other. Box 2 highlights the use of qualitative vs. quantitative Programme:
Evaluation
methodologies in evaluation.
Box 2 The Use of Qualitative vs. Quantitative Methodologies in Evaluation

The use of qualitative vs. quantitative methodologies in evaluation
l Qualitative methodologies are useful in monitoring and process evaluation
l Outcome/impact evaluation is often quantitative
l Both types of methodologies strengthen validity of findings
The evaluation should examine the project itself, rather than only the project’s impact.
It may provide an opportunity to analyze the administrative model, the extent of
institutionalization achieved, and so on. The results will help planners refine basic
programme designs. The evaluation may also provide an understanding of how and
why specific interventions were successful, rather than just the degree to which they
were. The evaluation may determine for what types of people the project worked, in
what circumstances, and for how long. Such insights are invaluable for making decisions
about directions of future interventions or about fundamental policies.
Another important thing, which you have to remember, is that evaluation should be
participatory and all those involved in the programme should participate in the evaluation.
We will now study how do we conduct a participatory evaluation.
18.7 CONDUCTING A DYNAMIC AND

PARTICIPATORY EVALUATION
You must be wondering who are the people who should participate in an evaluation.
The persons concerned with evaluation may be divided into four categories. These are
population itself, change agents in the communication process, evaluation specialists
and sponsors and government representatives. Let us study these briefly. Let us start
with population.
— Population with whom the programme is conducted should be invited to participate
in an evaluation processs since the actions to be evaluated, concern them directly.
— The change agents in the communication process play an important role in
evaluation process, as they learn from the process and can also improve their
performance.
— The evaluation specialists, internal or external to the project provide technical
expertise for the evaluation.
— Participation of sponsors and government representatives will allow them to
see the impact of the activities which they have promoted so that they can raise
more funds and consider further expansion of the programme.
When we involve community in the evaluation, it helps to create a bond of trust with
the community. We can find out their feelings about the benefits and weaknesses of
our activities, we can draw on their experiences and insights on what has happened.
Evaluation becomes a learning process and the community is able to reflect on its
experiences and plan future activities. An evaluation should ensure participation of all
the people involved in the NEC programme.
There are three types of tools which have been proposed, to carry out a dynamic and
participatory evaluation. These are: Causal analysis, hippopoc table and dynamic model.
We will review these briefly now. Let us start with Causal analysis.
417
Public Nutrition l Causal analysis: We discussed causal analysis of the nutritional problems in the
conceptualization phase. This can help determine the relevance of the interventions.
You may recall that causal analysis consists of creating an intersectoral setting
and network of factors which affect nutritional status of population. It helps to
select an appropriate intervention, develop communication between intersectoral
teams and for evaluating the relevance of the intervention. Causal analysis also
enables us to identify confounding factors which can influence the success and
failure of the intervention.
l Hypothietical Inputs Process - Output Outcomes Table: Once the causal analysis
is completed, a hippopoc table is constituted. In hippopoc table, as highlighted in
Table 18.1, inputs, procedures, outputs and outcomes of the intervention are
organized in the form of a table. The inputs are the elements which will be
transformed into outputs by intervention. For example, money, materials and even
type and number of people who carry out education activities. The processes are
the activities undertaken to transform inputs into outputs. For example, training
the educators, community mobilization etc. The outputs are the results of activities
carried out in the intervention. They correspond to specific objectives of the
intervention. They are direct effects of interventions. For example: support materials,
trained educators, etc. All these should contribute to the long term objectives of
any nutrition project that is improvement of nutritional status.
Table 18.1: Hippopoc Table – An example
Inputs Processess Outputs
l Amount of funds l Community mobilization l Number and type
l Type, number of equipment l Training of groups formed
used l Development of support l Number and type of
l Type and number of people materials educators trained
trained l Type and number of
support materials
produced
Once the hippopoc table is developed, we can seek answer to following questions:
l Has the nutritional problem to be solved been clearly carried out?
l Has the causal analysis been carried out?
l Has the formative research to understand the behaviours and the channels of
communication of the target population been carried out?
l Have the objectives been clearly defined in terms of modification of the nutrition
related behaviours and in terms of acquisition of attitudes, knowledge and skill
development?
l Have the messages been clearly developed?
l Has the multimedia plan taken into account the results of the formative research
and the specificity of the various media in the relation to the objectives to be
achieved?
l Have the communication support materials been pretested before producing them
on large scale?
l Have the participants been trained and retrained before the start of the
communication activities?
l Were the activities carried out in accordance with the plan?
l The outcome of the analysis is matched at the end with programme objectives
to determine success?
418
When we seek answers to these questions, we are assessing what we did and how Nutrition Education
we did, as planned for the NEC programme. Programme:
Evaluation
l Dynamic model
In the dynamic model, the relationship between the inputs, processes and outcomes are
illustrated in the graphic form. The graph could be used by all those involved in the
education programme to provide basic information in the project, to determine its
successes and failures and to plan for improvement.
Thus we studied that evaluation is like an energy source that can be drawn upon, for
development of participatory communication activities. Evaluation is not simply an
activity external to the intervention. It is a crucial component of nutrition education.
Let us now assume that we have conducted an evaluation of the NEC programme and
we find that changes have taken place in the target audience in terms of positive
behaviours. We would now have a question to ask ourselves. The question is that can
we say with certainty that changes in behaviours took place as a result of implementation
of our programme? We would like to find an answer to this question. Let us find out
about it in the coming section.
18.8 CONTRIBUTION OF NUTRITION

EDUCATIONPROGRAMME TO CHANGES
IN BEHAVIOURS
You have implemented a NEC programme and let us assume that evaluation shows
that changes in behaviours took place in target audience as expected. Now does it
really matter what factors helped your programme? Perhaps not. But if your programme
was an experimental pilot project testing out a new approach that you want to repeat
elsewhere, you would have to make sure that the improvements occured because of
the new methods and not for any other reason. If the objectives have been clearly
defined at the outset, it is not usually difficult to show that change has taken place in
your community. However, it is much more difficult to show that it took place because
of your own efforts and not because of another reason. There are two ways of
showing that change was caused by your own efforts. These methods are 1) by using
a control group, and 2) indirect method without using a control group for comparison.
This is called proving ‘causality’. Let us study these methods in detail. Let us study
the first method first.
1. Using control group: In the control group method, we can set up two test
groups. One test group that receives the nutrition education and the other group
as a ‘control’ which does not receive the education. The two groups should be
as close as possible in age, education, income and other factors likely to influence
impact. If the group that received the education achieves a better performance
than the control group, this will provide a strong evidence for the success of the
communication process. Figure 18.1 depicts the process of comparing changes in
test group and control group, if a control group was set up in the beginning of the
programme.
Test group receives

Measure baseline at education
Measure levels at
the beginning of the the end of the
programme “pre-test” programme
for test group and Control group “post-test”
control group does not receive
education
Figure 18.1: Comparison between test group and control group 419
Public Nutrition Thus, using a control group method, we can assess the change before and after the
intervention. If the test group shows a positive change in behaviour and the control
group does not show any change, then we can say that the change in the test group
occurred as a result of our interventions.
Let us look at the other method i.e. indirect method.
2. Indirect method without controls: If it is not possible to set up a control group,
we will have to use an indirect method for excluding other reasons for any
changes. We would have to carefully look at other possible explanations for the
changes that took place. We could interview in the community and ask them why
they changed their behaviour – was it because of the education programme or
were there other reasons? Figure 18.2 depicts the process for determining changes
without the use of control group.
Measure changes at
Measure baseline at end, ask questions to
the beginning of the Give education find out why people
programme “pre- changed and find out if
test” for test group it was because of the
education programme
Figure 18.2: Measuring change without the control group
We can note from the Figure 18.2, that we conduct a baseline survey in the beginning
of the programme to determine the current behaviours. We provide education and
then conduct a survey again to determine why people changed behaviours and if it
was as a result of our interventions.
So you saw how using the two methods, we can assess that changes occurred
exclusively due to the nutrition education programme. We have now studied all aspects
of an evaluation process. You can now develop an evaluation system, decide what
methods to use and conduct an evaluation of the nutrition education programme. We
will now recapitulate what we studied and review the main points, which should be
considered while planning an evaluation system in a NEC programme. These are as
follows:
i) Integrate evaluation in the programme from the planning phase.
ii) Clarify the purpose of the evaluation. Prepare a set of realistic, achievable and
measurable indicators for success.
iii) Develop an evaluation system, which takes account of all phases of the nutrition
education communication project.
iv) Whenever possible, set up control groups who do not receive the education. If
controls are not possible, collect data that will help to show that it was the
programmes effort that led to improvements.
v) Decide if the evaluation should be internal or external, or both.
vi) When evaluating inputs, make sure that programme objectives are properly specified
and that indicators are measurable and that the activities are relevant and feasible.
vii) Use multiple methods (triangulation) in data collection and analyses. This will
strengthen the validity of findings if the results produced by different methods
are congruent.
(viii) In analyses, be careful to control for extraneous confounding factors and bias.
(ix) Don’t limit to finding out if you have reached your objectives – look out for any
unplanned benefits or unexpected problems.
420
(x) Learn from your failures as well as successes. Find out why programmes Nutrition Education
succeeded or failed and what lessons can be drawn for the future. Programme:
Evaluation
(xi) Allocate adequate time to nutrition education programmes, with the timing of the
evaluation clearly identified.
Thus, we learnt that it is very important to conduct evaluation of a NEC programme.
We must incorporate evaluation plan into NEC programme right from the
conceptualization phase. In fact, we can conduct evaluation during any phase of the
NEC programme. The reason why so many well planned NEC fail at the implementation
level is because they have not in-built the evaluation plan into them. If we include an
evaluation plan in the NEC programme, we would be more likely to achieve success
in NEC programme. This will also give more credibility to nutrition education practice
and the programmes would not be seen with skepticism.
With the discussion above we end our study of evaluation.
1. What is the ultimate goal of nutrition education communication?
..........................................................................................................................
..........................................................................................................................
2. Explain these terms briefly:
a. Process evaluation
...................................................................................................................
...................................................................................................................
b. Summative evaluation
...................................................................................................................
...................................................................................................................
3. What are the main features of evaluation?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
4. How will you show that change took place because of the education programme?
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
18.9 LET US SUM UP

In this unit we learnt about the concept and purpose of evaluation. Evaluation is an
integeral part of programme planning and management and should be planned from the
beginning of the nutrition education programme. However, evaluation can be conducted
during any phase of the nutrition education programme. Evaluation involves showing
whether; the change has taken place or not, if the change took place, then did it happen
as a result of the programme and if the amount of effort required to produce the
change was worthwhile. We learnt about how to develop an evaluation system and 421
Public Nutrition different types of evaluation. Different types of evaluation are process evaluation,
summative evaluation and formative evaluation. We studied about two features of
evaluation. These are determining evaluation questions and selecting evaluation strategies
to answer these questions. We also learnt as to how we conduct a dynamic and
participatory evaluation.We concluded the section by discussing about the methods
used to assess if the changes in behaviour in a nutrition education programme took
place as a result of our efforts.
18.10 GLOSSARY
Pilot project : Activity planned as a test or trial.
Control group : A specific group designated in a research study where
participants are used as a standard for comparison and do not
receive any treatment.
Semi structured : Interviews conducted with a fairly open framework which
allow for focused, conversational, two way communications.
These are used to give as well as to receive information.

EXERCISES
1. In simple terms, evaluation means to judge the value of something. Evaluation is
a systematic and scientific process, determining the extent to which an action or
set of actions were successful in the achievement of pre-determined objectives.
Evaluation is also defined as the systematic application of social research procedures
for assessing the conceptualization, design, implementation, and utility of intervention
programmes.
2. Yes. Evaluation is an integeral part of programme planning and management,
because it involves measurement of adequacy, effectiveness and efficiency.
3. We need to evaluate nutrition education programmes to aid future planning and
to improve programmes, to increase our understanding of nutrition education
practice, to add to the body of knowledge upon which our work is based. We
evaluate to achieve operational efficiency and, related to this, to obtain data that
permit interpretation of programme effectiveness so as to obtain administrative
support, community support and donor support.
4. There are two main aspects which we need to keep in mind while developing an
evaluation system. Firstly goals and objectives of the programme should be linked
to evaluation. Secondly, we should also justify the use of resources or inputs i.e.
men, material money etc. through an evaluation process.
1. The ultimate goal of NEC programme is not people hearing advice but taking it,
changing their behaviour and ultimately improving their own and their children’s
health and nutrition as a result of the advice.
2. a. Process evaluation is a tool for monitoring progress. It indicates whether the
strategies and activities being implemented are likely to generate the expected
results. Process evaluation also indicates whether the work is done on time.
If the activities do not meet expectations, they may be changed or even
stopped.
422
b. Summative evaluation is the systematic use of research techniques to measure Nutrition Education
outcomes and overall programme effectiveness. Programme:
Evaluation
3. Main features of evaluation system are: a) Determining evaluation questions.
b) Selecting evaluation strategies to answer these questions. An effective evaluation
strategy should incorporate a number of different methodologies.
4. Changes taking place due to the efforts of the programme can be assessed by
two methods. 1) Using controls: one can set up another group as a ‘control’ who
does not receive the education and assess. 2) Indirect method without controls:
We could interview in the community and ask them why they changed their
behaviour – was it because of the education programme or were their other
reasons?
423
Public Nutrition
18.12 SUGGESTED READINGS
Beaton GH, Bengoa JM. Nutrition in Preventive Medicine. The Major Deficiency
Syndrome, Epidemiology and Approaches to Control. World Health Organization (1976).
FAO/WHO. Preparation and use of food-based dietary guidelines. Report of a joint
FAOIWHO consultation; Nicosia, Cypms. Nutrition Programme, WHO, Geneva (1996).
Mason J, Habicht JP, Greaves JP, Jonsson U, Kevany J, Manorell R, Rogers B. Public
nutrition. Letter to the editor. Am J Clin Nutr 1996;63:399-400.
Michel Andrien. Social Communication In Nutrition: A Methodology for Intervention.
Prepared By Development Support Communication Branch, Information Division;
Nutrition Programme Service, Food Policy And Nutrition Division. FAO (1994).
Michael J Gibney, Barrie M Margetts, John M Kearney, Lenore Arab. Public Health
Nutrition. Blackwell Science, Blackwell Publishing Company (2004).
National Nutrition Policy. Department of Women And Child Development, Ministry of
Human Resource Development, New Delhi, Government OfIndia, 1993.
National Nutrition Monitoring Bureau, Annual Report, 1991. Hyderabad, National
NutI:ition.DfNutrition, 1991.
National Nutrition Monitoring Bureau, Report of Repeat Survey (1988-90). Hyderabad,
National Institute Of Nutrition, 1991.
Park K. Bhanot B. Heath care of the community. In Preventive and Social Medicine
16th Edition (2000).
Policy On Management Of Vitamin A Deficiency. Ministry of Health And Family Welfare,
Government Of India, 1991.
Policy On Control Of Nutritional Anaemia. Ministry of Health And Family Welfare,
Government Of India, 1991.
Rogers BL, Schlossman NP . “Public nutrition: The need for cross disciplinary breadth
in the education of applied nutrition professionals.” Food and Nutrition Bulletin 18:2,
120-133, 1997.
Txnth Five Year Plan (2002-2007), Vol.lI, Sectoral Policies & Programmes, Nutrition,
2003.
Wasting Away- The Crisis of Malnutrition In India.World Bank.
Willett Walter. Nutritional Epidemiology. Oxford University Press, Oxford, New York
(1990).
National Nutrition Monitoring Bureau, Annual Report (2015-2016). Hyderabd, National
Institute of Nutrition.
Twelth Five Year Plan (2012-2017), Volume III, Social Sector Planning Communication,
Government of India, 2013.
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Annexure - 1A Nutrition Education
Programme:
Guidelines for conducting a diet survey using 24-hour recall method Evaluation
l First collect background information i.e. family particulars regarding age, sex,
physiological status and occupational status of the members.
l Collect information regarding the meal pattern i.e. the type of preparation made for
breakfast, lunch, tea, dinner during the previous day.
— Note down the name of the preparations in local term.
— Note down raw ingredients used in the preparation
— Record amount of each raw ingredient in terms of actual weight if known or
approximate weight in terms of local measures or with the help of standard
measures as indicated below:
Food stuff Local measure Weight in gm
1) Bengal gram dal 1 pav 250
2) Onion 4 small ones 120
3) Cauliflower 3 pav 750
4) Oil 3 tsp 15
5) Spices (Corriander powder) 1 tsp 5 mg
l Record the amount of cooked preparation in terms of measuring cup. If the
housewife is unable to give the amount in terms of cup, then ask them to fill the
vessel used are the preparation with water upto the same level (approximate) as
for the preparation. Then measure this volume for the total cooked amount.
l Note the amount of food or portion size served to each member from each of the
preparations made in the family.
— Note the amount in terms of cups, for each individual.
— If flesh foods (such as mutton, fish etc.) is considered, note the total amount
cooked in terms of number of pieces and the number given to each individual.
— In case of oil, sugar note the intake in terms of standardised spoons and
ladles.
— If the individual is an infant, make a note of breast feeding practices and/or
supplementary foods given.
l After collecting this basic information, calculate the intake of the individual in terms
of raw amount using the following formulae.
Raw quantity (g) of each
Individual intake in terms preparation used by the family
of raw amounts of food =  Individual Intake
Total cooked amount (volume)
of each preparation
For example 1/2 kg (i.e. 500 g) of raw rice was cooked (1400 ml water) for the family.
The total weight of the cooked rice was estimated to be about 2 kg (20000 gm). Out of
this preparation an individual consumed say 100 g (measured with the standard cup),
then the amount of raw rice eaten by the individual can be worked out as under:
500
Amount of rice taken by the individual = x 100 = 25 g.
2000
l Once the amount of raw food is known, we can refer to the Food Composition
Table [given in the Practical Manual-I] and estimate the nutrient content of the
food consumed by the individual.
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Public Nutrition Annexure - 1B
Assessment of dietary intake of an individual (child) in the family using 24-hour
recall method of Diet Survey
1) Identification particulars:
Date
Place (Town/City/Village) District Block St
Name of child
Name of Father/Guardian Age (yrs-mths) Sex
Address
2) Socio-economic details of family

Father Mother Other sources of income
Occupation
Total income (Rs./ps/month)
Age group (yrs.)
Family composition : 0-1 1-3 3-5 5-7 7-9 9-12 12-21 21
Total
Male
Female
3) Breastfeeding status of the child: EBF/PBF/Weaned
Relationship and age of the person Relationship Age(yrs)
feeding the child when the mother
is away for work:
4) Dietary intake:
Meal pattern Amounts used by the family Intake of an
previous day individual (child)
Name of Ingre- Raw Cooked Cooked Raw

Prepa- dients amount quantity quantity equiva-
ration used g/ml g/ml lents
g/ml
(i) (ii) (iii) (iv) (v) (vi) (vii)
Early morning
Breakfast
Mid-morning
Lunch
Tea & Snacks
Dinner
Others
a) (Meals/snacks
taken outside
home)
b) Supplements
from any,
of the feedings
programmes, if
any (specify)
426
Annexure 2 Nutrition Education
Programme:
FOOD FREQUENCY QUESTIONNAIRE Evaluation
Schedule for assessment of Qualitative dietary pattern of family
1. Identification particulars :
S. No. Date :
Name of the village/ Block : Dist : State :
Urban area
Name of the Respondent :
Address :
2. Socio-economic status of family :
Occupation of the head of the family :
Family size
and Composition Age groups (yrs)
0-1 1-5 5-12 12-18 Adults Total No. of Total family

earning income Rs/
members p.m
Sex :
Males
Females
Total
Educational
level :
Type of family : Nuclear/Extended/Joint

Physiological status of woman : Pregnent/Lactating/Non-pregnant &
Non-lactating
Number of absentees/guests/servants/pots in the family :
3. Dietary pattern of the Family :
DIETARY INFORMATION
Frequency of usage
of foodstuffs Sources Raw cost Name
of getting quan- kg. pre-
food tity per Rs. para
Daily 3/wk 2/wk 1/wk 1/mth Season stuffs* (g/ml) Ps. tion
in
which
used
1. CEREALS:
Rice
Wheat
Jowar
Ragi
Others
2. PULSES/
LEGUMES:
427
Public Nutrition
DIETARY INFORMATION
Daily 3/wk 2/wk 1/wk 1 /mth Season Sources Raw cost Name
in of getting quantity kg. preparation
which food per Rs.
used stuffs* (g/ml) Ps.
3. GREEN
LEAFY
VEGETA-
BLES:
Spinach
Amaranth
Cabbage
Kethi
Others
4. Radish
Carrots
5. OTHERS
VEGETA-
BLES
6. FRUITS :
7. MILK
AND
MILK
PRODUCTS
8. SUGAR
AND
JAGGERY:
9. OILS &
FATS
10. FLESH
FOODS :
Meat
Beef
Poultry
Fish : Fresh
DryEGGS
11. MISCELLA-
NEOUS
FOODS
12. LESS
FAMILIAR
FOODS
428
Nutrition Education
LIST OF ABBREVIATIONS Programme:
Evaluation
AIDS Acquired Immune Deficiency Syndrome
ANM Auxillary Nurse Midwife
AG Adoloscent Girl
AAY Antodaya Anna Yojana
AWW Anganwadi Worker
AWC Anganwadi Centre
APL Above Poverty Line
BOAA Beta-oxalyl Amino Alanine
BMI Body Mass Index
BPL Below Poverty Line
CMO Chief Medical Officer
CNS Central nervous System
CED Chronic energy Dificiency
CU Consumption Unit
CDPO Child Development Progress Officers
CBC Communication for Behaviour Change
CIP Central Issue Price
CSSM Child Survival and Safe Motherhood
DG Director General
DTP Diptheria, Tetanus, Pertussis
FAO Food and Agricultural Organization
FCI Food Corporation of India
FAD Flavin Adenine Dinucleotide
FMN Flavin Mononucloeotide
FPS Fair Price Shop
GNP Gross National Product
GDP Gross Domestic Product
GOI Government of India
HIV Human Immunodeficiency Virus
HDI Human Development Index
HCC Hydroxy Cholecalcieferol
ICDS Integrated Child Development Scheme
IAP Indian Academy Paediatrics
IU International Units
ICAR Indian Council of Agriculture Research
IDA Iron Deficiency Anaemia
IDD Iodine Deficiency Disorders
IMR Infant Mortality Rate
IRDP Integrated Rural Development Programme
IFA Iron and Folic Acid
IEC Information, Education, Communication
IU International Unit
IUD Intrauterine Device
IEC Information Education and Communication
KSY Kishori Shakti Yojana
L.D.C. Lower Divisional Clerk
LHV Lady Health Visitor 429
Public Nutrition MUAC Mid-Upper Arm Circumfrence
MPR Monthly Progress Reporting
MMR Measles Mumps Rubella
NCHS National Council for Health Statistics
NNMB National Nutrition Monitoring Bureau
NIN National Institute of Nutrition
NNACP National Nutritional Anaemia Control Program
NMMP National Midday Meals Program
NRR Net Reproduction Rate
NFHS National Family Health Survey
NREP National Rural Employment Programme
NSSO National Sample Survey Organization
NEC Nutritionl Education Communication
NE Nutrition Education
NPAN National Plan of Action on Nutrition
NNP National Nutrition Policy
NFHS National Family Health Survey
NGCP National Goitre Control Programme
NIDDCP National Iodine Deficiency Disorder Control Programme
NFFWP National Food for Work Programme
NOAPS National Old Age Pension Scheme
NICD National Institute of Communicable Diseases
NSPE National Support to Primary Education Programme
OPV Oral Polio Vaccine
PHC Primary Health Centre
PDS Public Distribution System
PEM Protein Energy Malnutrition
PMGY Pradhan Mantri Gramodya Yojana
PRI Panchayati Raj Institution
QALY Quality Adjusted Life Index
RDA Recommended Dietary Allowances
RFA Recommended Food Allowances
SC Sub Centre
SD Standard Deviation
SM Social Marketing
SFB Soya Fortified Bulgur
SGRY Sampoorna Grameen Rozgar Yojana
SGSY Swarnajayanthi Gram Swarozgar Yojana
SNP Special Nutrition Programme
TBA Trained Birth Attendant
T.B Tuberculosis
TGR Total Goitre Rate
TIP Trials for Improved Practice
TT Tetanus Toxoid
TDPS Targeted Public Distribution Scheme
U.D.C. Upper Divisional Clerk
UNICEF United National Children's Education Fund
UN United Nations
U5MR Under 5 Mortality Rate
UNDP United Nations Development Programme
UNICEF United Nation International Children Education Fund
VAD Vitamin A Deficiency
WHO World Health Organisation
430
Nutrition Education
Programme:
Evaluation
NOTES
431
Public Nutrition
NOTES
432

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MFN- 006

M.Sc. (DFSM) Expert Committee

Dr. Umesh Kapil

M.Sc. (DFSM) Programme Coordinator

MFN-006 Course Coordinator - Prof. Deeksha Kapur

MFN-006 Course Design and Preparation Team

Dr. Sushma Sharma (Unit 6) Dr. Shubhada Kanani (Unit 15-18)

MFN-006 Course Revision Team

July, 2019 (Revised)

1.4 Health Care

1.5 Role of Public Nutritionists in Health Care Delivery

1.8 Answers to Check Your Progress Exercises

Box 1 Definition of Health

Let us now go over to the term public nutrition.

1.3 PUBLIC NUTRITION

1.3.3 Future Projections

Check Your Progress Exercise 1

1.4 HEALTH CARE

1.4.1 Concept of Health Care

1.4.2 Levels of Health Care

 Tertiary health care

9%  Secondary health care

Primary health care

Figure 1.2: Levels of Health Care

1.4.3 Primary Health Care

Box 3 Declaration of Alma Ata Conference

14 Figure 1.3: Essential components of primary health care

1.4.4 Health Care Delivery

Figure 1.4: Administrative division of India

Figure 1.5: Organs of health system at central level

Let us look at each of these organs in detail, next.

l Union Ministry of Health and Family Welfare is headed by a Cabinet Minister

Let us move on to the state level.

B. Health System at the State Level

Figure 1.6: Organisation of health services at state level

Let us now move on to the district level.

Figure 1.7: Organisation of health services at district level 17

Community Health Centre (CHC)

A 30 bedded Hospital/Referral unit for 4 PHCs with specialized services

Primary Health Centre (PHC)

Figure 1.8: Rural Health Care System in India

Source : Rural Health Statistics, 2017. Accessed https://daa.gov.in//

Source: Rural Health Statistics, 2017.

Let us now learn about each system in detail.

Figure 1.9: Community Health Centre

Primary Health Centre (PHC)

Figure 1.10: Functions of primary health centre

Figure 1.11: Village health guide

State Health State Hospitals

District Health District Hospitals

Medical Officer Community Health

Block Medical Officer Primary Health Centre

Village Health Workers Sub-centre

Community Health Guide

Figure 1.12: Health service delivery system in India

1.5 ROLE OF PUBLIC NUTRITIONIST IN

Check Your Progress Exercise 2

2. List the essential components of primary health care.

1.6 LET US SUM UP

Promotive services : the services provided to the members of the community to