Changing Nutrition Scene In South Asiac. Gopalan

The countries of South Asia,(Bangladesh, Bhutan, India, Maldives,Nepal, Pakistan and Sri Lanka) with1.3 billion people account for 37 percent of Asia's population and 22 percent of the population of the world.International reports such as the Hu­man Development Report' have ac­corded a low ranking to some of thesecountries in the developmental scale.While the validity and utility of theseinternational ran kings can be chal­lenged, it must be conceded that thecountries of South Asia have facedand are still facing major problemsrelated to undernutrition.

However, the present situationin these countries has to be seen andunderstood in the total historical con­text. Practically all the countries ofthis Region could be considered tohave started on their developmentaljourney just five decades ago, withthe attainment of their political inde­pendence. During the last five de~cades these countries have, in fact,registered some remarkable gains andthese must be recalled:

• Large-scale famines, which usedto devastate vast sections of the popu­lation of this Region with distressingregularity for centuries, have beeneliminated.

• Florid forms of malnutrition suchas beri-beri (cardiac and dry), pella­gra, keratomalacia, famine edema, clas­sical kwashiorkor, pendulous goitresand osteomalacia have been elimi­nated. The Indian subcontinent was averitable museum of these most florid

forms of undernutrition. These havenow ceased to be the major publichealth problems, which they once were.

• Cereal (wheat and rice) productionhas nearly kept pace with populationgrowth, ensuring that the per caputavailability of food grains has notdeclined. This has been achieved in

spite of a tremendous population riseduring the past 50 years, from456 million in 1950 to 1.3 billion in2000.

• Death rates of infants and childrenhave been drastically reduced andlife expectancy has risen (Table 1).

THE UNFINISHED TASKS

While the gains of the past havebeen impressive, a great deal moreneeds to be done before the prob­lems of poverty and malnutrition inthis Region are fully eliminated. Thetasks ahead are indeed formidable.Four such major tasks that requireour immediate attention are mentionedbelow.

Food production: 'Food secu­rity' of earlier years was largely lookedupon as a quest for freedom fromstarvation and hunger. The calorieadequacy yardstick has been themeasure of achievement in this re­gard. Unfortunately, the Green Revo­lution, which saved the lives of mil­lions in this Region, has led to somedistortions with respect to the patternof food production. Thus, whereascereal production had soared, theproduction of pulses (poor man's pro-

tein) has stagnated with the resultthat the per capita availability of pulseshas actually declined2• Horticulturaldevelopment has been very tardy. Withregard to milk production, India hashad some striking results, largely dueto the imaginative co-operativeprogrammes of the type initiated byDr V. Kurien.

On the whole, the production of"quality foods" has not kept pace withincreasing requirements. The resulthas been that there has been no sig­nificant improvement in the quality ofhousehold diets. Durable improvementin the nutritional status of populationscan be achieved only by ensuringqualitative and quantitative adequacyof household diets. This is a majorchallenge.

It will be a formidable task tomeet the increased demands (Table2) for quality foods by the end'of thenext decade in the context of shrink­age of land size holdings, scarcity ofwater and electric power and declin­ing yields per hectare. Clearly newimaginative strategies and safe newtechnologies will be needed to achieveadequate production of a range offoods.

CONTENTS• Changing Nutrition Scene

In South Asia1

- C. Gopalan• Nutrition News

5

•Recent Transitions in

Anthropometric Profile ofIndian Children: Clinical andPublic Health Implications

6- H.P.S. Sachdev

• Foundation News

8

TABLE 1Infant Mortality Rate, Under-five Mortality Rate and Life Expectancy in South Asia

Countries

InfantUnder fiveLife ExpectancyMortality

Mortality(in Years)Rate (per 1000)

Rate (per 1000)

1960

20001960200019602000

India

23669236884463

Bangladesh

24779247834061

Pakistan

226952261104364

Nepal

2971802971053859

Sri Lanka

13317133186273

Bhutan

30084300-3762

Maldives

300623006644- Anti-poverty programmes in thisRegion have been generally under­taken as short-term relief operations,which would yield immediate relief.These may be justified perhaps indealing with situations of distress likedroughts and floods. The poverty syn­drome has many synergistic attributes.(Figure 1) The problem of povertycannot be "solved" or pushed underthe carpet through populist reliefprogrammes. Our strategy must be toattack the root causes of poverty ratherthan its symptoms. Even modest in­puts addressed to the alleviation ofroot causes of malnutrition in a plannedmanner, converging on a populationgroup, would yield significant results.Relief programmes could be an ad­junct to this effort.

The central part of any such strat­egy should consist of programmesfor the aggressive spread of educa­tion, especially female education, andfor imparting income-generating skills,which would facilitate creation of largenumbers of blue-collar jobs. It is throughsuch efforts, which are calculated toimprove the quality of our human re­sources, and not through short-termrelief operations, that we can hopefor a durable solution of the povertyproblem.

Child survival and stunting: Whilethere have been striking improvementswith respect to child survival, this hasyet to be followed up to the point ofachieving optimal child health/nutri-

Poor hygiene & housing;unhygienic environment

~Infection

.-------

FIGURE 1

The Poverty Trap

Lack of awareness & poor----i~~ utilisation of available resources

1---------_~ Poor access to health care

1

Illiteracy &

lack of skills

have been reduced3. The fact thatthere has been an emergence of anurban middle class in the last decadenumbering over 200 million, presum­ably including a sizable number of'first-generation rich', would also in­dicate thatthe anti-poverty programmesare having an impact. Subsidised foodgrains at low prices are now beingmade available to the poor and at­tempts are now being made to evolvea more effective public distributionsystem. All the same, new imagina­tive strategies are necessary to com­bat poverty and quicken the pace ofpoverty eradication in this Region.

Source: Human Development Report 2000, Human Development In South Asia, 2000

Ensuring adequate access tofood: Much of the undernutrition seenin South Asia is attributable to the factthat sizable sections of the popula­tion do not have adequate access tofoods. We are, therefore, witness tothe cruel paradox of vast stocks offood grains posing storage problems,on the one hand, and sizable pocketsof undernutrition, on the other.

It has been claimed, on the ba­sis of certain criteria, that 30 per centof the population of the Indian sub­continent could be below the povertyline. Several anti-poverty programmeshave been undertaken in this Region.While these may not have succeededin eradicating poverty, they have cer­tainly helped to mitigate it. Disaggre­gated data analysed by the NationalNutrition Monitoring Bureau (NNMB)at National Institute of Nutrition (NIN)show that severe degrees of poverty

TABLE 2Estimates of Food Needsof India by 2010Production

(Million Tonnes )20012010

Food Grain

Production208266

Milk

84153

Vegetables

80117

Fruits

2243

Animal Products

613

2

TABLE 4Gestation Distribution Of Live Births

Gestation

U,S.A"'Norway "4India, NFl "5

(in weeks)(40000)(125485)(14128)

<37

5.355.0322

37

3.753.6113.2

38

9.408.5420.7

39

16.5219.723.1

40

39.2328.2713.5

>=41

25.7534.857.6

Figures within brackets indicates sample size

TABLE 3Stunting in South Asia

Country

Stunted(%)

Bangladesh

51

Bhutan

54

India

63

Maldives

30

Nepal

50.5

Pakistan

50.2

Sri Lanka

16.1

Source: WHO (1999)

tion. With modern health technology,it is possible to successfully applydeath control strategies even in thecontinuing context of poverty andundernutrition. As a result of a policywhere the chief objective was "childsurvival" ratherthan child health, therehas been an expanding pool of sub­standard survivors. Thus, more than50 per cent of children in this regionare stunted according to available re­ports. (Table 3)

Much has been written aboutstunting and quite a few gloomy con­clusions about the state of child healthin this Region have been drawn onthis basis. However I would like tosound a note of caution. We must

perhaps avoid drawing sweeping con­clusions regarding the state of childhealth in a country just on the basis ofprevailing heights of children in com­parison with an international standard.So-called "stunting" is after all a non­specific sign of multifactorial origin. Itcannot be considered as the 'GoldStandard' for evaluation of the childhealth of a nation. It is not stuntingper se, but the process that led to itand the precise factors involved in it,that lend it significance, These maynot be the same in all communitiesand in all stages of development.

There has always been a secu­lar trend in all developing countries,children of succeeding generationsbeing taller. According to reports, ittook 50 years (1880-1930) forthe seculartrend in Canada to plateau off. It maybe wrong to argue that Canadian chil­dren were stunted for nearly five de­cades. Similarly in Japan, the seculartrend has been on right from the endof World War II. Elimination of stunt­ing is, therefore, apparently a multi­generational phenomenon.

There is already some evidenceof secular trends with respect to heightseven among poorer sections of thepopulation3. We should promote thissecular trend, so that the populationsachieve the heights which are reflec­tive of their genetic potential.

Maternal health: An unfinished

task that must find high priority isnutrition care of the pregnant woman.Today nearly 80 per cent of pregnantwomen in this Region are anaemicand, even more importantly, nearlyone-third of infants born to them are

of low birth weight. The diets of preg­nant women in poor communities inSouth Asia are as poor, if not evenpoorer, than those of non-pregnantwomen.

Recent studies have indicatedthe long-term implications of low birthweights and intra-uterine growth re­tardation. In a long-term study ex­tending over 18 years, Shanti Ghoshand her colleagues as reported byS.K. Bhargava and V. Kapani4. hadshown that low-birth-weight infantscontinue to grow and develop in asubstandard growth trajectory as com­pared to children of the same socio­economic groups born with normalbirth weights. This would indicate thelong-term implications of intra-uter­ine growth retardation on subsequentgrowth in childhood. It is possiblethat some part of the stunting that wesee may be attributable to intra-uter­ine growth retardation.

More recent studies of Barker

and colleagues5 have indicatedthat subjects born with low birthweight are more vulnerable to chronicdegenerative diseases such as Syn­drome X and Type II diabetes in adult­hood. This finding must be of special

3

concern to us, considering that WE

have, on the one hand, a high inci·dence of low-birth-weight deliverie~and, on the other hand, an escalationof chronic degenerative diseases inadulthood.

An important factor, which hasnot attracted adequate attention, bulwhich probably contributes significantlyto low birth weight and intra-uterinegrowth retardation is that the gesta­tional age of live born infants in thepoor communities6 appears to be sig­nificantly shortened as compared tothose in the developed countries7,8(Table 4). Shortening of gestation periodseems to be an important attribute ofmaternal undernutrition. Even among"full-term births" in poor communi­ties, a high proportion of deliveriestake place in the 37th and 38th weekand not in the 39th and 40th week6,

Preliminary results of recent stud­ies undertaken by the Nutrition Foun­dation of India (NFl) show that regulardaily supplementation of iron and folateto pregnant women can significantlycontribute to reduction in the inci­dence of low birth weights. However,we did not find a linear relationshipbetween the severity of anaemia andlow birth weight. On the other hand,the addition of food supplementscontaining n-3 fatty acids (such assoya oil) over and above iron-folatesupplements could significantly cor­rect the shortening of gestation andincrease birth weights. The beneficialeffect of iron-folate supplementationmay be at least partly due to thefact that it facilitates the conversionof n-3 fatty acids to their activemetabolite (Figure 2).

If extended studies, which arenow ongoing, confirm these findings,

* indicates reference number

a-Linolenic (18:3)

l ....6-desaturase iron dependantOctadecatetraenoic acid (18:4)

1 "009'"Eicasatetraenoic acid (20:4) folic acid dependant

1 ..5-d"a'"""Eicasopentaenoic acid (20:5)

1

40353025

TABLE 5

Inexpensive Common Food Sourcesof Both Efa and Iron-folate

Pulses

Red gramBlack gramGreen gramLentil

Bengal gram

Green Leafy VegetablesSpinachAmaranthMint

Fenugreek leavesDrumstick leaves

of undernutrition and poverty withproblems related to unbridled and ill­regulated affluence. For the next 20years, South Asia will have to fight attwo ends of the developmental spec­trum. It must attempt to achieve com­plete elimination of undernutrition andpoverty, on the one hand and thedisturbing escalation of chronic de­generative diseases among the afflu­ent sections, on the other.

Information technology revo­lution: Information technology hasmade rapid advances in the past fewdecades and continues to do so. Ra­dio and television media have beenbringing information into the homesof largely illiterate populations, therebyopening a window to the world. Satel­lite imagery has been providing valu­able inputs about ground water re­sources, soil quality, weather, anddesirable cropping patterns. And now,with computers penetrating slowly but

%

15 20105

FIGURE 3

Urban Population (as % of Total Population) in South Asia

o

-

.1

2000

• 1975- I

I

Nepal

India

Bhutan

Sri Lanka

Pakistan

Maldives

Bangladesh

this section also appears to be themost vulnerable to chronic degenera­tive diseases such as obesity, Type IIdiabetes, Syndrome X, etc, becauseof changed lifestyles and dietary hab­its1O• There has been a debate as to

whether this vulnerability is geneti­cally determined or whether it is atransitional phenomenon arising fromthe fact that this middle class, sizablesections of whom have presumablybeen born in poverty and have ac­quired affluence in adulthood alongwith life-style changes associated withsuch affluence.

Whatever may be the explana­tion, the escalation of chronic degen­erative diseases poses a serious prob­lem. It would almost appear that SouthAsia may be exchanging its problems

Eicosanoids 3 series

FIGURE 2

Iron/Folic Acid - n-3 Fatty Acid Metabolism

FACTORS INFLUENCING FUTUREDEVELOPMENT

we would have placed in the hands ofhealth workers valuable informationregarding precise inexpensive andpractically feasible directions in whichdiets of pregnant women can be im­proved. There are several inexpen­sive foods which could supply bothiron/folate and essential fatty acidsavailable in this Region (Table 5).Ourattempts should be to promote theintake of such foods rich in iron and

essential fatty acids which are spe­cially rich in n-3 fatty acids for preg­nant women.

The major factors which are boundto have a profound influence on thenutrition scene of this Region are thefollowing: urbanization, informationtechnology revolution and globalisation.

Urbanisation: A major changein the last few years has been thelarge-scale movement of rural popu­lations to urban areas (Figure 3).Urbanisation implies not just a changein the location of the dwellings, butalso a change in life styles, value sys­tems and dietary habits. Whileurbanisation has had its positive ef­fects and has contributed to overalleconomic growth, it has also led toundesirable side effects. There hasbeen a rapid emergence of a newlyaffluent middle class (prone to di­etary errors and excesses) in the In­dian subcontinent9. This new middleclass has been, in many ways thespearhead of economic and overallnational development. Unfortunately,

surely into district, block and evenvillage levels, the wide world of theInternet is only a mouse-click away.

Governments, including localgovernments, and development sci­entists can leverage these availableinputs in imaginative and innovativeways to enhance nutrition informa­tion, hygiene awareness, better farm­ing practices and so on. Web pagesin regional languages will acceleratethe process of reaching target groups.A planned strategy to harness the fullpotential of information technologymust form an important part of anydevelopmental programme. Knowledgeis power. The best way to empowerthe poor and the vulnerable sectionswill be to equip them with knowledgeusing the modern tools of informationand technology. This could be a pow­erful help in combating poverty.

Globalisation: Globalisation

could certainly contribute to macro­economic development. But as KhadijaHaq cautions1, "If globalisation is su­perimposed on apoorly educated andpoorly trained labour force with poorsystems of governance and infrastruc­ture, it would not lead to growth norreduce poverty". Unless globalisationis accompanied by institutional changesand by rapid improvement in the edu­cationallevels of the poorest sectionsof the population, there could be afurther polarisation between the havesand the have-nots. The advent of

globalisation greatly adds to the ur­gency of the need for upgrading thequality of the poorer sections of soci­ety through the spread of educationand imparting of income-generatingskills.

In pursuing developmental ob­jectives, Asian countries should notmake the mistake of accepting the'western model' as perfect. It must beremembered that western countrieshad made many dramatic U-turns suchas return to breast-feeding, jettison­ing high saturated fat diets andrecognising the importance of veg­etables. Asian countries should seekto foster and cherish traditional prac­tices that have been proved to beconducive to general health and well­being. At the same time they shouldbe receptive to new ideas and newtechnologies of proven value and safetyfor combating undernutrition.

Paper presented at the opening session of the

IX Asian Congress of Nutrition.

References

1. Haq, M.U.: Human Development Center, Hu­man Development in South Asia, Islamabad, 2001 .

2. Gower, D.: Pulse crops in South Asia, Bi-weeklyBulletin, Vol 15 (10),2002.

3. National Nutrition Monitoring Bureau, Report ofSecond Repeat Survey. Report for the year 1996­97. National Institute of Nutrition, 1999.

4. Bhargava, S.K. and Kapani, V.: in LinearGrowth Retardation in Less Developed Countries.Raven Press, New York, Volume 14, pg 266, 1988.

5. Barker, D.J.: Intrauterine growth retardation andadult diesase. Curr Obstet Gynecol, 3, 200-206,1993.

6. The incidence of low birth weight deliveriesamong the poor; secular and seasonal trends there­in, and elucidation of possible underlying factors.Annual Report, Nutrition Foundation of India, 2000­2001.

7. Babson, S.G., Behrman, E., and Lessel, R.: Liveborn weights for gestational age of white middleclass infants. Paediatrics, 45:937-42,1970.

8. Bjerkdahl, T., Bakketeig, L., and Lehmann, E.H.:Percentiles of birth weights of single live births atdifferent gestational periods. Acta Paediatr Scan,62:449-54,1973.

9. Gopalan, C.: Nutrition research in South EastAsia: the emerging agenda of the future. Regionalpublication No 23, South East Asia. Regional Office(SEARO), New Delhi, World Health Organization,1994.

10. Gopalan, C.: Nutritional aspects of risingincidence of degenerative diseases and cancer. In:Nutrition in Developmental Transition in South East

Asia, Regional Health Paper No 21, World HealthOrganization, 1992.

NUTRITIONNEWS

• IX Asian Congress of Nutrition:The IX Asian Congress of Nutritionwas held at Hotel Ashok, New Delhifrom February 23-27,2003. India washappy to host the Congress for thesecond time. The First Asian Con­

gress of Nutrition was also hosted byIndia and was held in 1971 at

Hyderabad. The President of the IXAsian Congress of Nutrition, Dr C.Gopalan was also the President ofthe First Asian Congress of Nutritionand he was the one who had initiatedthis series.

Mr K.C. Pant, Vice Chairman ofIndia's Planning Commission, presidedover the Inaugural Function anddelivered a scintillating and informa­tive address indicating the proposedsteps that would be taken by the Gov-

5

ernment towards nutritional upliftmentof the population. This comprehen­sive address will form part of the Pro­ceedings of the Congress.

The Congress was organised bythe Nutrition Society of India and theNutrition Foundation of India underthe auspices of the Federation of AsianNutrition Societies (FANS). It was at­tended by over 1,350 delegates fromover 46 countries. The ScientificProgramme consisted of 6 PlenaryLectures, 6 Plenary Sessions, 30 Sym­posia, Oral Free Communication andPoster Sessions.

The Scientific Programme pre­sented a proper balance between thebasic scientific aspects and practicalapplications. The Congress providedan opportunity for scientists from dif­ferent countries to interact with eachand share experiences.

Dr C. Gopalan was elected asthe President of FANS and Dr RameshV. Bhat as the Secretary General. Itwas unanimously decided that the XAsian Congress of Nutrition will beheld in Taipei.

• Third Course in Practical Paedi­atric Nutrition: The Third Course inPractical Paediatric Nutrition was jointlyorganised by the Centre for Researchon Nutrition Support Systems (CRNSS)and the Apollo Centre for AdvancedPaediatrics (ACAP) on March 8-9, 2003in New Delhi. In contrast to a largeCongress, the primary objective ofthe Course was to provide a practicalapproach to the administration of en­teral and parenteral nutrition in thehospitalised child and was intendedprimarily to target the practicing clini­cians and dieticians. The Course wasattended by over 60 delegates whohad the opportunity to interact withthe faculty through intensive brain­storming sessions, involving practi­cal day-to-day problems encounteredduring the nutritional management ofcritically-ill patients.

• Report of the Steering Commit­tee on Nutrition for the Tenth FiveYear Plan (2002-2007): This report,which has just been released by thePlanning Commission, is a compre­hensive document, which deals withthe current nutrition scene in the countryand the possible action programmesthat could be undertaken during theTenth Five Year Plan. This report shouldbe of interest to all nutrition and healthscientists.