‘The basic issue is of poverty and equity’

Interview with Professor H.P.S. Sachdev, Member of the Technical Advisory Group, CNNS.

Professor H.P.S. Sachdev.

nationally conducted Comprehensive National Nutrition Survey (CNNS) was to collect nationally representative data on the nutritional status of preschool, school-going and adolescent children. The survey took on board many technical and medical experts to work on its design. One of them was Professor H.P.S. Sachdev, a Senior Consultant in Paediatrics and Clinical Epidemiology at Sitaram Bhartia Institute of Science and Research, New Delhi. His current research interests include developmental origins of adult disease; nutrition in children; adolescents and mothers in low and middle-income countries; and systematic reviews to guide policy and practice. Sachdev is totally opposed to (food) product-based interventions. He feels poverty and equity are the basic issues and that the government should not find quick-fix methods to address the findings of the survey.

Excerpts from an interview he gave Frontline :

As one who was associated with the design of the CNNS, what do you make of the figures thrown up by the survey, particularly those on undernutrition, anaemia and obesity? What is so unique about the CNNS?

We have been doing surveys looking at biochemical indicators for deficiencies and excesses. We used to look at data from the National Nutrition Monitoring Board surveys, which used to study the poorest of the poor. Those were projected as national estimates. Our estimates do not focus on any particular section as each economic group can throw up different results. Some of us felt we needed to look at anthropometry only and more specific bio-markers of nutrition. The United Nations Children’s Fund decided to do this. I was involved in the first cut of the study design. Several nutrient-based programmes have been pushed over the years and what always has been hurting me, including the recently released Global Hunger Index... which does not say anything about hunger. Poor body size, or undersize, is not an indication of starvation. We thought that to guide our policy, we needed more accurate and proximate estimates. Undernutrition leads to undersize and then starvation which calls for medical interventions and leads to pushing of products. One thing leads to another. On the one hand, there is undernutrition and starvation, and on the other, we are told that India is the capital of diabetes, hypertension and various non-communicable diseases. I am not saying that we are not undernourished, but undersize does not translate into hunger. There were no data on micronutrients and overnutrition situations. The survey was designed at the national level and was not specific to any group. The findings could have gone either way but our objective was to inform nutrition policy. The other thing I insisted on, along with others, was to have built-in quality checks. We felt that if the findings were unpalatable to the government and to those who were part of the commercialisation of development misery or involved in pushing poverty alleviation programmes, quality checks needed to be built in for robust data. There was an agency to check the fidelity of data and a few samples were re-evaluated. The CDC [Centers for Disease Control and Prevention, Atlanta] also participated in quality testing.

Anaemia levels are still high and there is, as always, a gender dimension to it.

One of the objectives was to get a correct estimate of anaemia. We were trying to look at what causes anaemia. Iron is one of the causes, maybe up to 50 per cent. The other causes are concomitant infections and other haemoglobinopathies [a hereditary condition involving an abnormality in the structure of the haemoglobin]. The vitamin A supplementation programme has been going on the basis of the National Nutrition Monitoring Bureau [NNMB] data. We have argued for substantial revision of the programme. There are many interesting findings. We have to be careful when we compare States. The first and foremost takeaway for me is that there is some good news, and policy should be directed on that basis. The levels of undersize are diminishing. Levels of wasting are lower compared with those obtained by the National Family Health Survey-4. The prevalence of anaemia is also low. Half of it is probably linked to iron deficiency, but other causes are also coming to the fore. The problem will not be solved by pushing iron supplement programmes. The role of haemoglobinopathies and parasites needs to be analysed. The release of this report was delayed. I don’t know why. It shows India in a good light.

Even if there is some improvement, there is a connection between household wealth and nutritional status.

It illustrates that ultimately it is a question of equity. But there are 20 other causes for people being undersized—the age of the mother at the time of delivery, her educational status, recurrent infections, and so on. All these factors contribute to mortality as well as the child’s overall health outcomes. On the one hand, fortification and supplementation is being pushed and then we say we have a problem of overnutrition. If two foodstuffs with the current supplementation are fortified, there have been instances when the total iron intake became excess. It is like when every fever was malaria. Malaria is a symptom.

Iodine status

Blindly supplementing and fortifying is not the solution. There will be a risk of causing harm. The iodine status indicators are also interesting. This survey shows that not even one State assessed by urinary iodine is deficient in iodine. Seven or eight States have levels above the recommended levels and two are in the toxic stages. So, we have to fix the iodine content. Some literature shows that in every family there is one person who is diagnosed with hypothyroid. Though the prevalence of goitre has been controlled, the level of iodine in salt needs to be regulated as that can create other problems. Regarding vitamin A and vitamin D deficiencies, I think there should not be a “one-size-fits-all” approach, which can create serious problems like excessive intake. The government needs to take a position on vitamin D supplementation.

Fortification of food is now the latest mantra to address micronutrient deficiencies and there are several players from industry who are interested in this sector. We are a huge market after all.

The biggest issue with fortification is that it also adopts a one-size-fits-all approach. Once you introduce it in a food item, it assumes permanence. For example, the way the iodine programme has been going on, no one questions it. There has to be some regulation. How many people can go on fighting it?

What is your understanding of lack of diversity and adequate diet patterns?

Quality diet is definitely required. The survey has data on egg and meat consumption and its relation to nutritional status. But our vegetarian population does not eat eggs and meat. How robust is the notion of a minimal acceptable diet? I am not sure, but even if it is, my surmise is it won’t make so much difference to stunting.

Would you say India is eating well?

Will there be a sea change if dietary quality changes is the question. It will be gradual. The food quality needs improvement. Dairy products, green leafy vegetables, fruits and eggs need to be part of the food basket. But how affordable are they? Even Western countries struggle with the norms of quality diet.

In India, there are issues relating to storage of fresh fruits and vegetables. We are self-sufficient. But product-based solutions are given to address hunger and nutritional deficiency. I believe that the food route should be adopted for improving quality and intake. This is an issue for addressing equity. The references have been made looking at children of well-to-do sections. To say that if food is infused with products it will bring about a sea change merely allows industry to come in and give product-based solutions. The government can save money from the vitamin A programme or reduce iodine in salt and address other components of development. The basic issue is of poverty and equity.

What is your view on quick-fix solutions? The government will at some point be compelled to react to the findings in the report as meeting the Sustainable Development Goals targets seems more important.

I have always been against such kind of solutions. There is hopefully a change in global thinking, too. We are basically a thin people. Just supplementing raw food will not build muscle. We were being used by industry to push products. We should evolve our own solutions. Fortification has to be done with clear-cut rules. Having both supplementation and fortification does not help. Multiplicity of interventions is not good. If one is anaemic and if iron supplementation is pushed to address that, it might help the person 50 per cent only. It might create other complications. Undernutrition and nutritional status is a generational thing. We should not forget about body size. Our sizes are not like that of Westerners.

While the basic food basket is shrinking, there is a burgeoning nutraceutical (nutrition products that are also used as medicine) industry as well.

Yes, it is here that the government should act and not push product-based solutions. The example of selling de-worming drugs on the grounds that they will increase weight, height and cognition has been proved wrong. There are studies now that show that it has no such effect. The drug decreases the worm burden, that is all. People must work on this dispassionately and not be swayed by anyone. Policy should be informed by the outcome of the survey and be evidence-based. There is more awareness now of conflict of interest. There has been some amount of tightening of protocols on nutraceuticals. Now, they cannot claim that their products mitigate, cure and control disease.