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
Top Related