Public Nutrition and Health

Written and reviewed by Anjali Sharma, Biology & Home Science faculty at UniDrill (M.Sc. Botany, Banaras Hindu University · 8 years teaching). Based on NCERT Home Science Class XII (Human Ecology and Family Sciences Part I), Chapter 3.

One Anganwadi, three very different children

At a village Anganwadi, a three year old is thin and weak. Another child of the same age is much shorter than her classmates. A third, from a town family, is overweight, yet is pale and tires quickly. All three are malnourished, in three different ways. When thousands of children share these problems, helping one child at a time is not enough. The answer must be organised action by society, which is the territory of public nutrition.

What public health nutrition is

Public health means collective action taken by society to protect and promote the health of whole populations. The mission of public health nutrition is to prevent both undernutrition and overnutrition, and to maintain optimal nutritional status of the population. The field is concerned with promoting good health by preventing nutrition related problems, and with the government policies and programmes aimed at solving them.

A community is a specific group of people who share common characteristics, for example a common language, similar exposure to conditions, a common lifestyle or the same health problem. A public nutrition professional must identify a problem and its magnitude, understand how and why it occurs, plan and implement strategies, and evaluate their impact.

Why it matters: the size of the problem

If these problems are not controlled in time, they affect physical growth, which may lead to smaller body size in adulthood, and also mental and cognitive development, with effects on productivity and quality of life.

Worked example: what the cost figures mean. The chapter gives the loss as more than 10 per cent of lifetime earnings for a person and 2 to 3 per cent of GDP for the nation. Take a hypothetical worker with lifetime earnings of Rs 60 lakh, and a hypothetical economy with a GDP of Rs 100 lakh crore.

So the worker loses more than Rs 6 lakh over a lifetime, and the hypothetical nation loses Rs 2 to 3 lakh crore. A common wrong step is to read "2 to 3 per cent of GDP" as a loss per person. It is a share of the whole national output.

LBW check. A newborn weighs 2.3 kg. Convert to grams: $2.3 \times 1000 = 2300$ g, and since $2300 < 2500$, the baby is classified as low birth weight.

The double burden. India mostly faces undernutrition, but overnutrition is rising. People have become more sedentary, walk less, and children in large cities play less outdoors. Food choices have shifted to processed food, fast food, snacks, western style foods, and even sweets and fried snacks, which are high in energy, sugar, fat and salt and low in other nutrients and fibre. Whole grains, pulses, vegetables and fruits have declined. This leads to weight gain, overweight and obesity, and diseases such as hypertension, heart disease, diabetes, cancer and arthritis. The double burden of malnutrition is the coexistence of undernutrition and overnutrition.

Infectious diseases still matter too: new ones like HIV/AIDS and older ones such as tuberculosis, hepatitis and malaria are increasing, and their effects are worse in people who are undernourished or whose immunity is lowered by obesity, diabetes or HIV/AIDS.

Beyond the textbook. For the exam: the double burden means undernutrition and overnutrition coexist in the same country. In reality: they can also coexist in the same household, or even in the same person, as in the town child above who is overweight and anaemic. Energy rich but nutrient poor food can add weight without supplying iron or vitamins. Why it matters: "overweight" does not mean "well nourished", and hidden hunger can hide behind a normal or high weight.

Why malnutrition happens: causes at three levels

Nutritional problems are not only about food. They arise from many linked factors. Poverty is often the underlying cause, and it worsens when families lack basic amenities such as toilets and safe drinking water, since poor sanitation and water borne disease cost working days and income.

All of these lead to malnutrition, disability and death. In short, the factors range from economic resources and agricultural policy (production and prices of food), through availability of health services and government policies, to political will and socio cultural factors.

Protein energy malnutrition (PEM)

PEM is caused by inadequate food intake compared with requirements, meaning insufficient energy and protein. It occurs in every society, although fewer people are affected in developed countries. Children are at greatest risk, but adults, especially the elderly, may be affected, as may people with diseases such as tuberculosis and AIDS. It is assessed through anthropometric measurements such as weight, height and head and chest circumference.

Worked example: naming the problem from measurements.

For child A, a normal body proportion with short height points to stunting, a long term problem. For child B, height is adequate but weight is low for that height, which is wasting. A common wrong step is to call any thin child "stunted". Stunting is about height for age, and wasting about weight for height.

Pause and predict: a child is short for her age but her weight is in proportion to her height. Is she wasted?

Check your answer: no. Her height for age is low, so she is stunted. Wasting needs weight to be low relative to height, and hers is in proportion.

Beyond the textbook. For the exam: marasmus comes from deficiency of food and energy, and kwashiorkor from protein deficiency. In reality: clinicians recognise marasmus by severe wasting and loss of fat and muscle, while kwashiorkor is typically accompanied by swelling (oedema) of the feet and face, so a child can look rounded even though seriously undernourished. Why it matters: "looks plump" does not rule out severe malnutrition.

Micronutrient deficiencies: the hidden hunger

If a diet lacks energy and protein it is likely to lack minerals and vitamins too. Hidden hunger is the term for micronutrient deficiency. Iron, vitamin A, iodine and zinc are of major concern, with growing concern about vitamin B12, folic acid, calcium, vitamin D and riboflavin.

The vicious cycle in VAD runs: vitamin A deficiency → greater susceptibility to infection → greater loss of vitamin A → deeper deficiency. Yellow, green and orange fruits and vegetables are good sources of vitamin A. IDD is common in the Himalayan belt from Jammu and Kashmir to Arunachal Pradesh, and in Andhra Pradesh, Karnataka, Kerala, Maharashtra and Madhya Pradesh.

Beyond the textbook. For the exam: iodised salt is a fortified food used against IDD. In reality: iodine in salt can be lost if salt is stored in damp or open conditions or heated for a long time, so households are advised to store it in a closed container and add it toward the end of cooking. Why it matters: fortification only works if the nutrient survives to reach the plate.

Strategies and programmes

POSHAN Abhiyaan (PM's Overarching Scheme for Holistic Nutrition) was launched in Jhunjhunu, Rajasthan, in March 2018. It targets stunting, undernutrition, anaemia (among young children, women and adolescent girls) and low birth weight, and is meant to monitor and review the implementation of related schemes. The Ministry of Women and Child Development implements it, in 315 districts in the first year and 235 in the second, with the remaining districts in the third year, using multi ministerial convergence.

Two broad strategies. The comparison below is a CUET staple.

Two views. For the exam: the long term goal should be to shift away from supplementation towards food based approaches. Another reading: public health practice often combines the two, using supplements to protect high risk groups quickly while food based measures take time to change what a community can grow, buy and eat. Why it matters: the exam answer states the goal, and the second view explains why supplements still have a place.

Nutrition programmes in the chapter.

Beyond the textbook. For the exam: ICDS covers children up to 6 years and pregnant and nursing mothers. In reality: ICDS began in 1975 and delivers its services through Anganwadi centres, and the National Food Security Act of 2013 later made access to subsidised food grains a legal entitlement. Why it matters: a timeline question may need the order of these schemes: ICDS (1975), then the National Food Security Act (2013), then POSHAN Abhiyaan (March 2018).

Health care: three levels

Health is a fundamental human right, and health care means more than medical care. It includes the services that promote, maintain, monitor or restore health.

The public nutritionist: scope and careers

A public (or community) nutritionist is well trained in nutritional science, nutritional needs through the life cycle, assessment, nutritional care, food science, educational methods, mass media and communication, and programme management.

The career avenues listed are community nutritionist in the preventive and social medicine (PSM) departments of hospitals, government nutrition programmes such as ICDS and the Food and Nutrition Board, voluntary organisations, consultancy, counsellors for schools and industries, teaching and research.

Exam traps

60-second revision

Where this chapter connects

• Previous: Clinical Nutrition and Dietetics is the one to one counterpart of this community level chapter.
• Next: Food Processing and Technology explains fortified and processed foods, a tool used in the strategies above.
• Class XI link: Nutrition, Health and Well Being introduces undernutrition, overnutrition and health definitions that this chapter builds on.
• Same unit: Early Childhood Care and Education covers the Anganwadi and the early years that nutrition programmes aim to protect.