Combating malnutrition through nutrient delivery techniques

 Authors: Prof. Amit Arora, Associate Professor, CTARA, Indian Institute of Technology, Bombay and

Ms. Nisha Pujari, Research Scholar, CTARA, Indian Institute of Technology, Bombay

 

“The doctors of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition.” – Thomas Edison

Good nutrition is an essential driver of sustainable development because it plays a critical role in brain development, generates broad-based economic growth, and signals the fulfilment of people’s rights to food and good health.  Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients (WHO, 2019).

Micronutrients are essential elements required in small quantities throughout our life to orchestrate a range of physical and mental functions to maintain health. The consequences of their absence are severe and lead to micronutrient malnourishment (CDC, 2019). According to the national data for India (NFHS-5), the condition of wasting and micronutrient malnutrition has worsened in the last few years. The most widespread and recognized micronutrient deficiencies are of iron, zinc, vitamin A, iodine, vitamin D, and folate, often occurring concurrently in the sample population (Suchdev, 2017). As per NFHS 5, the percentage of total children aged 6-23 months receiving an adequate diet is very low (~11.3%). Anaemic children aged between 6 and 59 months have also gone up significantly from 58.6% to 67.1%. Likewise, 59 out of 100  women aged 15-19 years are anaemic.

Many strategies have been suggested to combat micronutrient deficiencies, such as exclusive breastfeeding for the first 6 months, controlling parasitic infections, food fortification, food diversification and nutritional supplementation. Food fortification is considered as a relevant and potent intervention by the authorities to reduce the burden of micronutrient deficiencies among children and mothers. It involves adding micronutrients to processed foods, which increases their concentration and thus fulfilling dietary requirements.

The selection of nutrients is based on evidence of low intakes in a population and/or widespread nutrient deficiencies which vary between countries and populations. Fortification programs, therefore, need to be carefully designed to meet the nutrient needs of a given population. Food processing has enormous potential to both increase dietary-diversity and enhance concentrations of micronutrients in commonly consumed foods. Technologists and scientists are making efforts in employing food‐to‐food fortification, by adding micronutrient‐dense foods to food recipes at household as well as commercial level to increase their micronutrient quality. 

Food-based strategies to combat micronutrient malnutrition

Evidence-based interventions for malnutrition have been well studied and can be categorized as nutrition-specific (address immediate causes, often at the individual level) or nutrition-sensitive (address underlying causes, often at the community level). Policy and programme makers incorporate food-based strategies such as dietary diversification, food fortification and supplementation, along with other additional measures on food safety, nutrition education and public health. These approaches should be regarded as complementary, with their relative importance depending on local conditions and local needs. Food-based strategies are discussed as follows:

1. Dietary Diversity
   Increasing dietary diversity is a preferred way of improving the nutrition of a population because it has the potential to improve the simultaneous intake of many food constituents including micronutrients. Diverse diets have been reported to provide vitamins and minerals that prevent ‘hidden hunger’ and micronutrient deficiency diseases (Dulal et al., 2017; Jones et al., 2014; Nithya & Bhavani, 2018; Rosenberg et al., 2018). Increasing dietary diversity means increasing the consumption quantity and range of micronutrient-rich foods. In practice, this requires implementation programmes to improve the availability and consumption of different micronutrient-rich foods (such as animal products, fruits and vegetables) in adequate quantities, especially among those who are at risk or vulnerable to micronutrient malnutrition (Nithya & Bhavani, 2018). However, increasing dietary diversity on a sustained basis has its challenges. One is the introduction of behavioural change through counselling about different foods and their nutritional benefits. Lack of resources for producing and purchasing higher quality foods can sometimes present a barrier to achieving greater dietary diversity, especially in the case of poorer populations (L. Allen et al., 2006)
2. Supplementation
   Supplementation is the term used to describe the provision of relatively large doses of micronutrients, usually in the form of pills, capsules or syrups. Micronutrient supplements during pregnancy can act as a precautionary measure for reducing morbidity and mortality in infants and also in treating maternal complications during pregnancy (Lawn et al., 2014). In our country, supplementation programmes are run to provide iron and folic acid to pregnant women, and vitamin A to infants, children under 5 years of age and postpartum women. Recently, the Ministry of Health and Family Welfare (MoHFW) has launched the Weekly Iron and Folic Acid Supplementation Programme to meet the challenge of the high prevalence and incidence of anaemia amongst adolescent girls and boys.
   Supplementation usually requires the procurement of micronutrients in a relatively expensive pre-packaged form, an effective distribution system and a high degree of consumer compliance (L. Allen et al., 2006). Some adverse effects observed with high-dose supplements and logistical and human-resource constraints may result in non-compliance and the long-term sustainability of such programmes. In such cases, mass fortification of staple foods becomes an important option to combat vitamin and mineral deficiencies. There are fewer concerns related to mass food fortification and it can be a complementary intervention to supplementation for efforts to decrease vitamin and mineral deficiencies (Peña-Rosas et al., 2019).
3. Food fortification
   Food fortification involves adding micronutrients to processed foods. It describes the improvement of essential micronutrient content in foods to enhance the nutritional and health benefits with minimal risk to health. In many situations, this strategy can lead to relatively rapid improvements in the micronutrient status of a population, and at a reasonable cost, especially if an advantage can be taken of existing technology and local distribution networks (L. Allen et al., 2006).  There have been studies with single (Dean et al., 2020), dual (Jannasch et al., 2020), and multiple micronutrient fortification, including zinc, iron, copper, selenium, vitamin A, vitamin B complexes, vitamin C and vitamin E (Das et al., 2019). Minerals are fortified in their salt forms such as ferrous sulphate, ferrous gluconate, ferrous lactate, zinc oxide, zinc sulphate, zinc acetate, zinc chloride, calcium carbonate, calcium phosphate, tri-calcium citrate, calcium lactate, calcium lactate gluconate, calcium gluconate, etc. (Gharibzahedi & Jafari, 2017). Considering the regional diversity in terms of food availability, fortification should be done in a customized manner to ensure compliance. In addition, fortificants should be low in cost with good absorption, and well accepted by the target population in terms of taste and organoleptic properties. In most cases, it is preferable to use food vehicles that are centrally processed and to have the support of the food industry (Chadare et al., 2019).  However, of these three methods (dietary diversity, food fortification and supplementation), programmes that deliver micronutrient supplements often see a quick improvement in the micronutrient status of the targeted population. Food fortification tends to have a less immediate but nevertheless a much wider and more sustained impact. Although increasing dietary diversity is generally regarded as the most desirable and sustainable option, it takes the longest to implement (L. Allen et al., 2006; Gharibzahedi & Jafari, 2017).

Food-to-Food fortification

Food-to-food fortification is a technique of fortifying food products with one or more food ingredient(s), thus making nutrient-dense food. The incorporation of nutritious ingredients calls for modification in the original food recipe, creating a new product with higher nutritional benefits. Such fortification techniques offer a variety of tastes and textures that are unique along with enhanced protein, vitamin, fibre and/or mineral contents and beneficial effects on its quality (Platel & Srinivasan, 2016). Cumin, moringa and sesame-fortified bread and soy-butter, moringa and cumin-fortified salty biscuits demonstrated improved total content and bio-accessible minerals. Its inclusion in food products could be a useful alternative or complement conventional fortification. This will help to improve the mineral status of deficient populations. Food‐to‐food fortification often uses locally available foods to enhance the nutrient intake of the population. This approach consists of selecting and associating foods in such a way as to optimize the bioavailability of useful micronutrients to consumers.

IIT Bombay’s intervention

The Nutrition Groups at IIT Bombay emphasises the development of food-based nutrient-rich, safe, affordable and ready-to-use formulations. Achieving optimal nutrition through the intake of healthy foods has the capability to optimise the physiological functions of each human while ensuring maximum well‐being. The key variable of this research is the presence of macro and micronutrients in sufficient quantity without compromising on quality parameters. Our research team at IIT Bombay is working on developing products with the capability to deliver the full range of micronutrients mostly through the natural product route, avoiding the chemical route. Our aim is also to create local capacity among women’s SHGs or social start-ups for decentralized production with appropriate Quality Control and Quality Assurance protocols. Given the priority accorded to health and nutrition projects in CSR funding, support to the food products lab can go a long way in addressing the problem of hidden hunger among malnourished children and women and benefit the programme implementation in aspirational districts

Some of the products which have been developed in CTARA are – 

(i)    Egg equivalent Idli and nutrition bar  
A completely vegetarian formulation was developed in the form of nutritious ‘Idlis’ and bars that can act as nutrition replacements provided by non-vegetarian foods such as eggs. The product’s theoretical nutrient profiling shows that 2 units of Idli or 1 standard Nutri bar are sufficient to give equivalent nutrition to an Egg. 


(ii)    Magic add-on dry powder 
This powder can be added to any given homemade recipe (e.g. Puree, daliya, Khichdi, dal-rice etc.) and as a result, the child will get a majority of the essential nutrients required for optimal growth and development. The major advantage here is gaining nutrient adequacy without changing dietary habits or preferences. Financial calculations for the developed formulation (DF) suggest that affordability is achievable at a mass-product scale to achieve reasonable dissemination and ultimately greater impact on children.

Other examples include Healthy alternatives to commercially available Ready to Use Therapeutic Foods (RUTF)

Challenges of food fortification
 
Theoretically, the fortification techniques aim at the efficient lowering of micronutrient malnutrition. These, however, still do not reflect in the micronutrient status of individuals based on reports. The following are some challenges faced during the choice and implementation of food fortification strategies:

1. a)     Cost 
   There is a lack of simple and affordable technology that can use stable and bioavailable nutrients while maintaining the commonly preferred taste and appearance of foods. Increased food prices remain an issue affecting the food security and livelihoods of the needy. Despite various international aid, basic foods are still not accessible because they are unaffordable to vulnerable groups who often grow and process their own staple foods. Major challenges to local‐scale fortification programs include the initial cost of the mixing equipment, the price of the premix, achieving and maintaining an adequate standard of quality control, and sustaining monitoring and distribution systems.
2. b)     Concerns about absorption and bioavailability
   Both the density and bioavailability of micronutrients in the diet are important for achieving optimal micronutrient status. Iron, zinc, and calcium can interact with each other to inhibit their respective absorption. For e.g. The ideal iron fortificant is highly soluble in water, similar to ferrous sulphate for the iron to be accessible for intestinal absorption. At the same time, the iron needs to be in a form that prevents it from interacting with dietary compounds that can induce undesirable organoleptic changes and reduce iron bioavailability by the formation of insoluble complexes. Fat-soluble vitamins such as vitamins A and E are poorly dispersible in water, making it difficult to incorporate them in beverages and foods with high moisture content.

Obtaining higher concentrations of micronutrients from food alone, to meet high RDA for adolescent girls and pregnant women is challenging. Processing techniques may lower anti-nutrients but at the same time, it may increase the risk of losses and degradation of minerals and vitamins, respectively.

c)     Toxicity

Toxicity may occur as a combined effect of more than one micronutrient. Increased instances of anaemia have been found in individuals with high levels of folate and low level of vitamin B12 (Rosenberg et al., 2018). Acute iron toxicity is usually seen in children with accidental ingestion of iron-containing syrups. Similarly, for zinc, folic acid, and selenium there are available documents with either reports on toxicity or regulation on the maximum limit (Food Safety and Standards Authority of India, 2019). Usual intakes below the upper limit have a low risk of adverse effects. Some nutrients do not have an upper limit because they are assumed to be safe at any level of intake (e.g., vitamin B12).

The goal of any national food fortification policy is to prevent nutritional deficiencies by bridging the gap between the requirement and availability of nutrients. In exceptional cases of widespread and severe deficiencies, the fortification can be up to 100% of the RDA. In practice, the level of fortification is about 15 to 30 % of RDA (computed per 600 calories of processed food) as per the regulations in India (ICMR, 2018). When these precautions are followed, food fortification carries a minimal risk of chronic toxicity.

1. d)    Anti-nutritional factors
   Poor dietary diversity and dependence on cereal-based diets are common in low- and middle-income countries. Cereals, in addition to being poor sources of vitamins and minerals, also contain high quantities of other dietary compounds, such as phytates, which decrease the absorption of certain micronutrients, often called ‘anti-nutrients’ (Graham 2001). One of the most important concerns in the processing of mineral-rich foods is the formation of strong complexes between bivalence elements (e.g., Ca2+, Mg2+, Zn2+, Fe2+, Cu2+), and phytate, oxalates, fibre, and compounds of tannin and lectin (Shubham et al., 2020). For instance, iron and zinc absorption is significantly inhibited by phytic acid, present in cereals and other grains; polyphenols, contained in red wine and chocolate; or calcium, abundant in dairy products (Peña-Rosas et al., 2019). 
   
   Crop Diversity and Nutrition Security
   
   To be able to reach the overarching goal of nutrition security through improved dietary diversity scores of children and mothers, access to high-quality and diverse raw materials has to be ensured. Crop diversity at affordable and scalable capacity would be central to the food-to-food fortification strategy. India is one of the largest countries in the world has to ensure self-sufficiency in food. The government’s initiatives to increase the production of rice, wheat, pulses, and other crops have brought India to a very secure condition in terms of calorie sufficiency as a whole. For example, rice alone contributes to 40% of total grain production in India followed by wheat (~34% contribution).

India is blessed with hundreds of highly nutritive indigenous crops which are popular in many regions. However, in the past six decades, India has witnessed a decrease in the area under such crops.

A classic example is the production volume decline in the variety of millets over the last few decades. Since there is no minimum support price for such crops, the generation of demand for such crops based food products to improve regional nutrition security would help farmers in realising better prices. Of course, this would entail partnerships with local grassroots organisations to build a sustained momentum to establish a strong value chain.  Safeguarding food and nutrition security through the promotion of diverse crop production systems should be looked at by policymakers more closely.

Conclusion 

Micronutrient malnutrition is a major impediment to socio-economic development. Vitamins and minerals have very different stability and bioavailability in the food matrix. Therefore, the development of a fortification technology that makes them bioavailable and more compatible with the food vehicle would be crucial.  To quantify the size of the gap between usual intakes and requirements in a population group, the distribution of usual intakes by individuals in the population groups of concern (e.g., young children or women of reproductive age, low socioeconomic status) should be compared to the average requirement. A concerted effort is needed for the development of ready-to-consume food products rich in multiple micronutrients, addressing food accessibility and affordability issues, while enhancing bioavailability and forming efficient food synergies. 

“Those who think they have no time for healthy eating will sooner or later have to find time for illness.” – Edward Stanley

REFERENCES: CLICK HERE

Contact author: Prof. Amit Arora
Email: aarora@iitb.ac.in 
Profile link –  https://sites.google.com/site/personalwebpageamitarora/

Water and Sanitation – Challenges and Opportunities for enhancing governance in rural / tribal areas

Water and Sanitation – Challenges and Opportunities for enhancing governance in rural/tribal areas

Authors: Paresh Vora, Director, India Operations, WIN Foundation, and Dr. Yogesh Jadeja, Founder and Director, Arid Communities and Technologies

 

“Water touches every aspect of development and it links with nearly every Sustainable Development Goal (SDG). It drives economic growth, supports healthy ecosystems, and is essential and fundamental for life itself. Some 2.2 billion people around the world do not have safely managed drinking water services, 4.2 billion people do not have safely managed sanitation services, and 3 billion lack basic handwashing facilities.”

– World Bank

The Government of India has recognised the massive challenges in Water and Sanitation domain and launched the Swachh Bharat Abhiyan, Atal Bhujal Yojana and Jal Jeevan Mission. Water shortages and poor quality affect hundreds of districts. Our agriculture suffers from vagaries of water supply, seriously affecting the food and nutrition security of the country as well as livelihood of small farmers.

The annual natural water cycle provides us limited fresh water, mostly during monsoon, stored on surface as well as in the ground and then used over the season, till the next supply arrives. On the other hand, the increased demand for water due to modern lifestyle and industry have led us to over-use surface water and over-extract ground water. This has lowered water levels and increased salinity in ground water. This, coupled with pollution due to human and industrial contaminants, has added to the water problems.

Before looking at solutions, a few key points worth noting: (i) While items like petrol, gets used-up, i.e. converted to another substance, water “usage” converts typically water to impure or polluted water. Proper treatment and recycling can increase the supply of available water. (ii) Nature’s water cleansing processes are inadequate for our levels of pollution. E.g. Human waste will take many months to decompose, while  chemicals and plastics may take tens of years. (iii) Agriculture uses about 90% of water. Optimized water use in agriculture increases yield and also preserves soil health. (iv) Water is basic to all life on earth. So it is also important to use water in a manner which protects the living ecosystems around us.

Hence, governance model for water at various levels of government needs to focus on: (i) conservation, (ii) optimized usage, (iii) recycling and reuse of water.  

Water governance also needs to be decentralized to the lowest administrative levels, due to distributed nature of storage and consumption and agriculture being largest user of water. Villages panchayat and associated groups should form the bedrock of water governance.

The newly launched Atal Bhujal Yojana and the Jal Jivan Mission offer an excellent opportunity to create sound and long term water governance structure, including policies, rules and regulations, protocols among participating administrative bodies, with participation by all stakeholders. This document, primarily talks of water governance in villages

Objectives of Water Governance

Villages desire water security, to ensure that their water demand for all uses are met from the available water supply. Thus both supply and demand side management is required.

The inflow of water in a village is based on rainfall, river, springs or canal inflows brought to village. This water is stored in rivers or springs, lakes, ponds, open wells and ground water aquifers. Water storage optimization is the key need.

The largest usage of water is in agriculture, with other major uses being family, cattle, and any industries located in or around the village. Thus agricultural practices, including crops selected, have the largest impact on demand for water. Optimized water usage, not only conserves water, but also results in better agricultural productivity and retains soil and water quality.

Village level

Hence, at the village level, the water governance system, should be centered on the Village Panchayat. The system should include (i) understanding Water supply and demand, creation and implementation of water security plan and water resource management protocols. (ii) impact measurement and corrective actions. Water Resource Committees, together with Farmers groups, Women groups, and similar bodies need to be involved as stakeholders and contribute to the decision-making. Village bodies need to ensure non-discriminatory decisions, so that water is provided in equitable manner to all.

Village panchayats can adopt suitable water policy legislation, in coordination with neighboring villages as well as nearby industries. This should be respected under the Panchayat act, with suitable methods for dispute resolutions in minimum time through administrative, arbitration or judicial means.

Cluster / Block / Taluka Level

Springs, rivers, canals and aquifers span across many villages and even districts. Hence coordination is required at village-cluster, block and taluka levels. At village cluster levels, the respective Panchayats need to develop mechanism to coordinate and cooperate on demand and supply issues. The taluka panchayats also need to play a role of coordination, when required to resolve differences. This will help village clusters to move from dependence to independence and then to inter-dependence to ensure more long term stability in water security, better ecosystem management, and economic and social progress.

District / State / National Levels

The towns, villages, industries, forests – all of them impact and are impacted by water governance in an interdependent manner. So a higher level coordination at the District, State and national level is required to ensure equitable solution for problems. E.g. The inevitable expansion of urbanization and industrialization cause overdrawing of water by the outlying urban colonies and reduces water for adjoining villages. This document does not aim to define these higher level governance structures.

While top-down approaches are important for initiating major changes as well as maintain the accountability and direction at higher level, a simultaneous decentralized approach at village and cluster / taluka levels is essential to bring a transformational change through participation by stakeholders at ground level. This alone can lead to tackling current challenges in water in more efficient and sustainable manner.

Skilling

Traditional water conservation structures and practices were implemented by village level skilled persons. Today it is imperative to develop a village level cadre (called Bhujal Jankars or Jaldoots) with training on traditional methods, upgraded with current technology and processes. Constant upskilling is required to adopt new methods. They need to understand water supply and demand, hydrogeology of the area, weather and rainfall, water conservation and recharge structures, testing and measurements, and ability to coordinate among various groups in the village.

The person should also have basic knowledge in agricultural practices and be able to coordinate with external agriculture experts.

This also creates livelihood opportunities at village level. With such a cadre, the Village bodies will have the knowledge and implementation expertise support to implement important supply and demand side initiatives.

 

Virtual Knowledge and Practice Excellence Centre

The skilled cadre of respective villages, will form a team, to study the cluster, block and taluka level issues and provide technical backup to the solutions implemented. This team needs to be linked to level experts from NGO’s, Institutions, Industry, Government, as required, for guidance on more complex issues.

Data and data analytics have emerged as a very powerful tool in all domains in twenty-first century. It has huge potential in agriculture, with its diverse data sets, huge amount of traditional and modern knowledge need to distill learning and make it available to farmers. Extensive data, captured from thousands of farms, on water, soil, weather, agricultural practices, inputs and outputs, prices, over period of years, enables farm level advisories for even marginal farmers cost effectively, and has potential to vastly improve agricultural science. This will go a long way to meet the farmer’s income needs and nation’s need to meet challenges of food and nutrition.

Thus, over a period of time, this body will form multiple virtual centre of excellence, capable of drawing from and contributing to higher level expertise, and support diverse local conditions and needs.

Evidence through Action Research under the Participatory Ground Water Management Program by ACT:

Most of the above steps have been implemented under the Participatory Ground Water Management project, carried out by Arid Communities and Technologies, with support from WIN Foundation and Tata Power Ltd. In  cluster of 19 villages of Mandvi Taluka in Kutch district in Gujarat, local youth were trained as Bhujal Jankars and in turn they prepared village level water security plans in discussion with village communities, under guidance from ACT. Supply side interventions and demand side interventions were carried out followed by introduction of innovations. Knowledge management systems were developed, including protocols, processes and data system. This has enabled replication in other locations: (i) Khambhalia area in Dwarka district and (ii) Abdasa and Nalia talukas in Kutch, with suitable adaptations for different hydrogeological, socio-economic, cultural conditions. 

This has created a virtual centre of excellence with collective knowledge within the community including the Bhujal Jankars, Farmers and Women groups and village panchayat. Higher level expertise and continuous training is provided by ACT, which also brings additional expertise e.g. KVK for  farming – KVK, and WIN Foundation for innovations. For gender equity, Women Bhujal Jankars are being increasingly trained and in turn they are initiating more activities through women groups, e.g. kitchen gardens with marginal farming families or ladies.

The local Panchayat bodies and Taluka development offices have also supported these processes.  Now, ABhY has adopted some of these processes for scaling up at National Level and ACT has been allocated 123 villages in Mandvi Block, 129 villages in Nakhatrana block, 25 villages in Anjar block, 14 villages in Bhachau block under ABhY.

Conclusion

Water is critical basis for life on our planet and essential for all aspect of human progress and quality of life. In our highly integrated and complex society, a knowledge and innovation based decentralized water governance with supportive centralized structure and practices, is essential for proper management of water for long term sustainability of our planet.

To quote the father of our nation, Mahatma Gandhi, “The earth, the air, the land, and the water are not an inheritance from our forefathers but on loan from our children. So we have to handover to them at least as it was handed over to us.” 
We owe it to the future generation to take the right steps.

Note: Views expressed by author are personal.
 
About the authors:

Mr. Paresh Vora, is Director, India Operations, WIN Foundation (www.winfoundations.org). Link to Prolife – click here. Mr. Paresh Vora can be reached for any comments/feedback at: paresh@winfoundations.org
 
Dr. Yogesh Jadeja is the Founder Director, Arid Communities and Technologies (ACT, https://act-india.org/), Bhuj, Gujarat, a dedicated organisation for Participatory Ground Water Management. He has nearly 3 decades of experience in water conservation. Dr. Yogesh Jadeja can be reached at his email id yogeshjadeja2129@gmail.com, for any comments/feedback.