Improving impact of programmes/Schemes:

National Nutrition Mission, Mid day meal

programme

Dr. A. Laxmaiah, MBBS, DPH, MPH, Ph.D, MBA, PG Certificate in Applied Nutrition

Scientist ‘F’ (Sr. Deputy Director: Epidemiology) & Head,

Division of Community Studies, NIN, ICMR, Hyderabad -7

National Nutrition challenges

Macronutrient Malnutrition

Protein energy malnutrition

a) Clinical PEM

b) Sub-clinical PEM

Micronutrient Deficiency

a) VAD

b) IDA

c) IDD

d) Zinc

e) Other vitamins and minerals

Diet related non-communicable disease

Obesity, diabetes, hypertension, CVD, cancers

162 million children with stunted growth in 2012

Source: UNICEF, WHO, The World Bank. Joint Child Malnutrition Estimates.

(UNICEF, New York; WHO, Geneva; The World Bank, Washington, DC; 2013

PERSISTANT LOW BIRTH WEIGHT -TRENDS

Source: UNICEF, The state of the World’s children 1992, 1996 and 1998

Country Percentage of infants with low birth weight

1980-88 1990 1990-94 1994-96

Bangladesh 47 50 50 50.0

Indonesia 14 14 14 11.0

Maldives …. …. 20 20.0

Myanmar 16 16 16 ….

Sri Lanka 25 25 25 18.0

Thailand 12 13 13 7.3

India 30 33 33 30.0

Maternal BMI and LBW

53.1

41.4

35.9

27.7 26.4

14.720

0

10

20

30

40

50

60

70

Pe

rce

nta

ge

<16 16-17 17-18.5 18.5-20 20-25 25-30 >30

Source: Nutrition News, National Institute of Nutrition, Hyderabad, 1991,12

NFHS 1: 1992-93

Under 3 years

Stunting Underweight Wasting RSoC: Rapid Survey on Children

NFHS 2: 1998-99

Under 3 years

NFHS 3: 2005-06

Under 3 years

NFHS 1 1992-93

Under 3 years

RSoC: 2014-15

Under 5 years

Source: NFHS 1, NFHS 2, NFHS 3, NFHS 4 & RSoC (2014-15

Stunting Underweight Wasting

DETERMINANTS OF NUTRITIONAL STATUS

• PDS • Rural Dev. Prog.

• Employment generation prog.

Availability of &

participation in

developmental

programmes

• Food production

• Land Ownership

• Type of land

• Rain fall

• Geographic conditions

• Agricultural techniques

• Use of hybrid seeds

• Use of fertilizers

• Population

• Family Size

• Urbanisation

• Religion • Community • Occupation

• Income

Drought/Floods Wars

• Illiteracy

• Ignorance

• Taboos • Infections

• Diarrhoeas • Resp. Infections

• Malaria • Others

• Infestations • Hook worms

• Round worms • Giardiasis etc.,

• Environmental sanitation

• Personal hygiene

• Safe drinking water

H H FOOD

SECURITY

FOOD

INTAKE

NUTRITIONAL

STATUS

Agro-climatic factors Demographic factors Socio-economic factors

Disasters

Socio-cultural

factors

Environmental factors

Pathological Conditions

Physiological factors

• Pregnancy • Lactation

• Breast feeding practices

• Infant & child Feeding practices

Low Birth Weight infants are at higher risk

for subsequent undernutrition (6-36 months)

0

10

20

30

40

50

60

Underweight Stutning Wasting

54.9

37.8

31.1 27.6 23.7

20.1

<2.5 >=2.5

***

***

**

Perinatal

18%

Others

32%

Ac. Res. Inf.

19%

Malaria

5% Measles

7%

Diarrhoea

19%

Impact of undernutrition among preschool children:

Source: Murray & Lopez, 1996: Pelletier et al, 1993

Malnutrition 54%

The direct or indirect cause of child death is undernutrition in

about 54% total deaths

Integrated Child Development Service Scheme (ICDS)

Mid Day Meal Programme

National prophylaxis Programme for control of Vitamin A

deficiency

National Prophylaxis Programme for control of Nutritional

Anemia

National Control of Iodine Deficiency Disorders (IDD)

Balwadi supplementary Nutrition Programme

National Diarrhoeal Diseases Control Programme

National Nutritional Programs in operation

Integrated Child Development Services (ICDS)

The programme was launched in the year 1975. The ICDS

today represents one of the world’s largest programmes for

early childhood development. Objectives of ICDS: 1. Lay the foundation for proper psychological development of

the child.

2. Improve nutritional & health status of children 0-6 years.

3. Reduce incidence of mortality, morbidity, malnutrition and school drop-outs.

4. Enhance the capability of the mother and family to look after the health, nutritional and development needs of the child

5. Achieve effective coordination of policy and implementation among various departments to promote child development.

Integrated Child Development Services

Implementing Agency is DWCD, GOI. GOI proposes to cover all Community Development

Blocks (CDB) By the year 2000 Currently, the programme is in operation over 6118 CDB

Under this programme, the package of services are being provided by an integrated approach for converging basic

services through community-based workers and helpers: Supplementary Nutrition Immunization Health Check up for minor ailments Referral Services Non-formal Pre-school Education Nutrition & Health Education (NHE)

Beneficiaries

Calories (kcal)

Protein (g)

Children 6-35 months

500

12-15

Children 36-72 months

500

12-15

Severely undernourished Children (6-72)

800 20-25

Pregnant & Lactating (P&L) Mothers and Adolescent girls

600

18-20

Supplementary Nutrition Norms

F. No. 5-9/2005/ND/Tech (vol.II), GoI, Min. of WCD, 24th February 2009

INCLEN Study

2009-11

Persisting undernutrition:

Social, cultural and environmental determinants

Ministry of HRD, Govt of India

MDM PROGRAMME

The programme was launched in the year 1962-63,

subsequently it was changed as ‘National Programme of

Nutritional Support to Primary Education (NP-NSPE) on

15th August 1995 as a Centrally Sponsored Scheme.

Objectives

Increase school enrolment, retention rate, regular

attendance reduce drop out rate and Nutritional Status.

• Tamil Nadu is in the forefront of organizing MDM since

1956 (as Chief Minister’s Noon Meal Programme).

• Children receive one meal every day,450Kcal energy and

12-15g protein/day for about 300 days in a year.

• As per the directive of supreme court hot cooked meal is

being served in all the states.

Nutritional

Content

Norm as per

NPNSPE,

2004

Revised Norm as per

NPNSPE,

2006

Calories 300 450

Protein 8-12 15

Micronutrients Not prescribed

Adequate quantities of micronutrients like iron, folic acid, vitamin-A etc

Nutritional Norms in MDM

Impact of MDM Programme: Karnataka

Year MDM School Non-MDM

school

1989 - 1990 14.5 27.3 ***

1990 - 1991 13.5 36.3***

1991 – 1992 18.4 35.5***

1992 - 1993 15.7 33.3***

Drop out Rate

Laxmaiah et al 1999

Impact of MDM Programme: Karnataka (contd.)

Wt/Age % of NCHS Stds

MDM Non - MDM

Grade IV (< 60) 18.5 20.8

Grade III (60-69.9) 40.0 41.5

Grade II (70-79.9) 28.8 26.6

Grade I (80-89.9) 9.7 9.8

Normal (> 90) 3.0 1.3

Laxmaiah et al 1999

Variables - No. of Feeding days

< 90 90

Retention Rate - 46.3 56.2*

Drop out Rate - 29.7 23.5*

Weight foe Age (% NCHS Std.)

< 60 11.4 15.4

90 2.8 2.7

Waterlow

Classification

% Normal 61.0 59.0

% Stunted 26.0 27.5

% Wasted 9.3 10.0

% Wasted & stunted

3.7 3.5

Effect of Regularity of MDM Programme

Sarma KVR et al, Asia Pac J 1995; 8 (1): 48-52

Variables - No. of Feeding days

< 90 90

Retention Rate - 46.3 56.2*

Drop out Rate - 29.7 23.5*

Weight foe Age (% NCHS Std.)

< 60 11.4 15.4

90 2.8 2.7

Waterlow

Classification

% Normal 61.0 59.0

% Stunted 26.0 27.5

% Wasted 9.3 10.0

% Wasted & stunted 3.7 3.5

P < 0.01

Effect of Regularity of MDM Programme

Sarma KVR et al, Asia Pac J 1995; 8 (1): 48-52

Pa

rtic

ula

rs

Pro

tein

s (

g)

En

erg

y (

K c

al)

To

tal F

at

(g)

Calc

ium

(m

g)

Iro

n (

mg

)

Vit

am

in A

(µ

g)

Th

iam

in (

mg

)

Rib

ofl

avin

(m

g)

Nia

cin

(m

g)

Vit

am

in C

(m

g)

Die

tary

fo

late

(µg

)

Primary School children (4-6 & 7-9y)

Through

MDM*

10.7 402 6 62 2.8 15 0.2 0.1 2.6 2.9 32

Home Diet ** 30.5 1137 16.1 212 7.9 76.5 0.4 0.5 8.5 17 79.4

Total amount

consumed

/day

41.2 1539 22.1 274 10.7 91.5 0.6 0.6 11.1 19.9 111.4

ICMR RDI$ 30 1690 60 600 16 600 0.8 1.0 13 40 120

% of RDA 137.3 91.1 36.8 45.7 66.9 15.3 75 60 85.4 49.8 92.8

Upper Primary School children (10-12y& 13-15y)

Through

MDM 11.0 448 6 76 2.3 11 0.2 0.1 1.8 23.2 9.9

Home diet* 36.3 1368 17.6 239 9.6 8.4 0.9 0.6 10.6 22 93.7

Total amount

consumed

/day 47.3 1816 23.6 315 11.9 9.5 1.1 0.7 12.4 45.2 103.6

ICMR RDI# 47.0 2320 77.5 800 27.5 600 1.18 1.38 14.5 40 147

% of RDA 100.8 78.3 30.5 39.4 43.3 1.6 93.2 50.7 85.5 113 70.5

Median intakes of nutrients among School going

Rural children

Nutrients Median

intakes

Recommended

dietary Allowance

(per day/Child)

Gap in the Nutrient

intakes

(per day/Child)

Deficit

(% of RDA)

Protein (g) 35.0 35.1 0.1 No deficit/

Negligible

Total fat (g) 17 33 16 - 48.5

Energy (Kcal) 1307 1905 598 - 31.4

Calcium (mg) 233 704 471 - 66.9

Iron (mg) 9.1 20.1 11 - 54.7

Vitamin A (µg) 82 600 518 - 86.3

Thiamine (mg) 0.9 0.9 Nil Nil

Riboflavin (mg) 0.5 1.1 0.6 - 54.5

Niacin (mg) 10.0 13.5 3.5 -25.9

Vitamin C (mg) 20 40 20 - 50.0

Folic acid (µg) 90.5 130.4 39.9 - 30.6

Age group (y) RDA* Existing MDM Nutrition Norms

Energy (g) Protein (g) Energy (g) Protein (g)

4-6 1350 20.1 450 12

7-9 1690 29.5

10-12 B 2190 39.9

700 15-20 10-12 g 2010 40.4

13-15B 2750 54.3

13-15G 2330 51.9

Primary School children

6-10y 1700 30 500 15

1/3rd of RDA 567 10

Upper Primary School children

11-14y 2320 47 700 20

1/3RD OF RDA 773 16

Basis for revision of Nutrition Norms

* RDA:Report of Expert group of the Indian Council of Medical

Research (2010), Nutrients Requirements and Recommended Dietary

Allowances for Indians, ICMR 2010.

Improving the nutrition quality of the school

feeding program (Mid-Day Meal) in India through

fortification Sadhana Bhagwat et al Asia Pac J Clin Nutr 2014

Fortification of Wheat flour

• 100 g of wheat per child per day is provided to children by the

Government of India.

• Wheat flour is milled in-house in all the kitchens where rotis are

served.

• Flour was fortified with iron, zinc and folic acid providing 5.5 mg of

iron, 0.22 mg folic acid and 2.2 mg zinc per child per day.

• Fortified whole wheat flour was used for making roti on the three

days when rotis were served.

• The cost of fortifying wheat flour was less than US$ 0.02 per child

per year.

Lacunas and bottle-necks of the NNP

Lack of regular super vision, monitoring and mid course

corrections for the project

Irregular supply of foods and consumable items.

Lack of transport facilities

There is no storage facilities for storage of food

supplements.

There is no government buildings for AWCs and other

institutions

Recommendation

• Fortification of staples

• Strengthening of programmes

• Establishment of regional Nutrition surveillance and monitoring

• Centers in 6 regions of country to get real time data

Prevention

Is

Better

than cure

THANK YOU FOR PATIENT HEARING