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CONTEMPORARY ISSUE
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 369-373  

Supporting efforts to address malnutrition in the context of the COVID-19 pandemic in India: An emergency need


1 International Food Policy Research Institute, New Delhi, India
2 UNICEF India, New Delhi, India
3 Indian Coalition for Control of Iodine Deficiency Disorders, New Delhi, India
4 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
5 NITI Aayog, New Delhi, India
6 UNICEF, Madhya Pradesh, India
7 The Coalition for Food and Nutrition Security, New Delhi, India
8 Tata Trusts, Mumbai, Maharashtra, India

Date of Submission09-May-2021
Date of Decision10-May-2021
Date of Acceptance10-May-2021
Date of Web Publication17-Jun-2021

Correspondence Address:
Chandrakant Sambhaji Pandav
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_338_21

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  Abstract 


India has been on a steady march to address malnutrition in the last decade. The nutrition community has worked on building consensus on key actions, implementation platforms were put in place and financing for nutrition slowly increased. Under the strong leadership of the Prime Minister, a revolutionary program to address malnutrition was launched in 2018. As actions under the mission accelerated, the COVID-19 pandemic arrived in early 2020. Affecting health systems, food systems, nutrition programs, social safety nets, and the economy, the pandemic has the potential to exacerbate the challenge of malnutrition in multiple ways. India can mitigate some of the possible ways in which COVID-19 will affect malnutrition but will require strong leadership and continued commitment, adaptation of the national nutrition mission, strengthening of the social safety net and innovative evidence-based data to take informed decisions, implement them and ensure feedback to take necessary corrective action. In this article, we outline some challenges and key areas for action. We conclude that India's nutrition journey is too important to be derailed by a crisis like COVID-19. This is a clarion call for the nutrition community in India to rally strongly to support continued attention to malnutrition in all its forms, to generate relevant evidence, and to support and engage all of society to urgently and adequately address malnutrition in the context of the COVID-19 pandemic. We have come too far to turn back now.

Keywords: Anganwadi, coronavirus, food, malnutrition, novel COVID-19, nutrition, pandemic, POSHAN abhiyaan, social distancing


How to cite this article:
Menon P, de Wagt A, Reddy V, Reddy K, Pandav CS, Avula R, Mathews P, Kaur S, Pawar S, Ranjan S, Sharma S, Sankar R. Supporting efforts to address malnutrition in the context of the COVID-19 pandemic in India: An emergency need. Med J DY Patil Vidyapeeth 2021;14:369-73

How to cite this URL:
Menon P, de Wagt A, Reddy V, Reddy K, Pandav CS, Avula R, Mathews P, Kaur S, Pawar S, Ranjan S, Sharma S, Sankar R. Supporting efforts to address malnutrition in the context of the COVID-19 pandemic in India: An emergency need. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Aug 2];14:369-73. Available from: https://www.mjdrdypv.org/text.asp?2021/14/4/369/318692




  Introduction Top


Introduction of the COVID-19 pandemic and its impact on nutrition

The COVID-19 pandemic has affected the world in unprecedented measures and drastically changed the ways in which people live and work. Its influence is palpable in almost every sphere of human existence. While this pandemic has caused havoc in the short-term, its long-term effects on health and nutrition are yet to be grasped. In low- and middle-income countries like India, this pandemic has the potential to further damage the already poor nutritional status of vulnerable groups due to multiple reasons – loss of income, strain on the fragile health-care systems, and disruptions to cash and food transfer schemes.

Research suggests a multi-level framework[1] will be needed to support nutrition and food security during the COVID-19 pandemic. At this critical point, while the number one priority of policy-makers is to save lives though COVID-19 prevention and management, we must also understand the short- and long-term impacts on food and nutrition security, including on potential increases in overall mortality.


  COVID-19 and Malnutrition: What do we Know? Top


How does COVID-19 affect malnutrition in the individual (and how does malnutrition in the individual affect COVID-19)?

Even though it is not fully known how COVID-19 affects malnutrition in an individual and how malnutrition in an individual affects the COVID-19 infection, it is widely proven that good nutrition, which helps in maintaining immunity[2] in an individual, is essential for preventing and managing viral infections. People with low immunity and underlying health conditions are found to be particularly susceptible[3] to COVID-19.

Pregnant and lactating women and young children who are malnourished could be vulnerable to COVID-19, as could younger adults who have underlying health conditions such as diabetes, hypertension, asthma, and those who are immune-compromised. India will be one of the first large countries with high levels of maternal and child undernutrition, and increasing noncommunicable diseases among younger adults to experience the onslaught of COVID-19.

Learning about the ways in which the infection and undernutrition intersect will be important in this context. Researchers have reviewed evidence[4] from previous clinical trials that evaluated nutrition-based interventions for viral diseases (with special emphasis on respiratory infections), and proposed that nutrition principles based on these other studies could be useful in the possible management of COVID-19.

How are COVID-19 and associated necessary actions likely to affect POSHAN Abhiyaan and progress on nutrition?

During the pandemic, India's public health care and care for women and children through Integrated Child Development Services (ICDS) and the health systems, already overstretched, in many places, experienced a challenge to maintain quality services. In addition, in a widespread environment of fear, it was also a challenge to attract clients to use antenatal, neonatal, and other health and child care services during the pandemic. These issues can influence the pace of improvement that we have seen in the past in the nutritional status of vulnerable groups.

The health and nutrition interventions that are delivered in India through ICDS and National Health Mission (NHM) platforms cover most evidence-based interventions in the first 1000 days essential for improving pregnancy outcomes and preventing growth faltering and poor development among children. In 2016, at the national level, the highest level of coverage for key nutrition interventions was about 65% and for most interventions, coverage was just about 50% or less. There was, however, major significant state-level variability in the coverage of these interventions [Figure 1].
Figure 1: Coverage of selected interventions across the continuum. Data Source: National Family Health Survey - 4 (2015–2016)

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During the pandemic, in most states, anganwadi centers (AWCs) under ICDS Scheme were closed initially and several services were disrupted. For instance, provision of hot-cooked meals, home visits, and growth monitoring services has been suspended. On a positive note, however, in many states, frontline workers are home delivering these food supplements[5] to those who are entitled to Take-Home Rations or to Hot-Cooked Meals under the ICDS Supplementary Nutrition Programme.

At the same time, intra-household food distribution, especially among the most distressed families can be a serious issue. Earlier, preschool children (3–6 years) used to consume hot cooked meals at AWCs themselves; in the current scenario, the home delivered food rations will likely get distributed among other family members, thus compromising the purpose of the supplementary nutrition program. Enriching the home delivered foods with more child-specific nutritious foods could help; some states have initiated this by proving foods such as peanuts and jaggery along with cereals and pulses.

In such times of uncertainty, however, disruption to critical preventive care services is likely to have serious implications including rise in maternal and child mortality.[6] States which have built up their systems before pandemic emergency situation are likely to be able to respond relatively quickly to the changing demands due to COVID-19 and bounce back at the end of this pandemic. For example, states such as Chhattisgarh, Gujarat, Odisha, and Tamil Nadu, all considered to be the success cases in service delivery, have invested in strengthening their implementation systems through long-term efforts. In the mid-2000s, these states complemented major national efforts like the scale-up of ICDS and introduction and scale-up of NHM with state-specific innovations. The situation may be quite different in other states, where existing capabilities and delivery mechanisms are not as robust. However, it is certainly possible that the crisis will force a greater investment in systems strengthening in lagging states. Thus, scenarios can play out differently in different states depending on where they stood before the crisis in terms of infrastructure, staff capabilities, delivery systems, effectiveness, responsiveness, and efficiency.


  How can India Preserve Progress on Actions to Tackle Malnutrition and Achieve POSHAN Abhiyaan Targets in the Context of the Pandemic? Top


Implementing essential interventions with coverage, continuity, intensity, and quality (C2IQ) and adequate protection for Field Level Workers

It is important to focus on implementing the essential nutrition interventions with enhanced coverage, continuity, intensity, and quality (C2IQ) with the convergence of services by the five key functionaries at the community level – Auxiliary Nurse Midwife, Accredited Social Health Activists, Anganwadi workers, Agriculture Extension Workers, Self Help Groups (SHGs), and Village Health, Sanitation and Nutrition Committee members – for better outcomes. Along with ensuring uninterrupted universal coverage of selected evidence based on nutrition interventions (with a special focus on children under 2 years of age, pregnant and lactating women and adolescent girls), safeguarding adequate financing to deliver at-scale these essential nutrition interventions is very essential.

During the pandemic, a few creative interventions were used to improve outcomes. For example, delivery of Vitamin A linked to immunization instead of campaigns; Field Level Workers using WhatsApp groups to share and discuss information on breastfeeding and young child feeding; distribution of iron and folic acid supplements to school children when they come to pick up their school supplies or during home visits when schools are closed; door-to-door delivery of take home rations for pregnant women and young children. Documenting and learning from these ongoing staff-led innovations on the ground can make an important contribution to supporting this arm of POSHAN Abhiyaan.

One approach to continuing to support implementation is through state-specific dialog to identify possible adaptations and learn from those. An example from one such effort, held early in the lockdown period, is from Madhya Pradesh and is summarized in [Box 1]. In addition, listening to both frontline workers on what they need to support effective implementation and ensuring their own safety is also going to be important to sustain service delivery. Similarly, listening to client populations on their fears and needs will also be crucial – in the end, the success of health and nutrition program services depends on the extent to which they are used and engaged with by client populations.



Extending compassionate support to address underlying social determinants, such as food and nutrition security, gender, incomes, and more

The associated economic impacts of COVID-19 can affect the underlying household drivers of malnutrition, especially food and nutrition security, gender issues, education, early marriage, and more. This means that actions to accelerate efforts to address food security,[7] including dietary diversity, primary health care, safe drinking water, environmental, and household sanitation are critical during the crisis. In addition, gender issues pertaining to girls' education, delaying age at marriage and early pregnancy, and reducing violence against women are imperative. This will ensure both adult well-being and will assure that children born into a post-COVID-19 world are protected from malnutrition.

Specific and urgent attention will be needed to ensure basic food and income security in a context of tremendous job losses, food insecurity, and reverse migration from cities back to villages – this is particularly of importance for the poorest. There have been numerous reports and early insights from surveys about the extent of the distress already, and while food safety nets are being increased in different states, this will need continued attention. Additional cash transfer programs to the poorest could help strengthen income security and buffer households against the income losses that are accompanying the pandemic.

Financing for nutrition-ensuring food and nutrition security efforts are insulated from funding cuts even in difficult fiscal circumstances

In a postpandemic scenario, with the global economic slowdown and overall budget cuts, financing for nutrition may also be badly hit. However, it is important to ensure that food and nutrition security efforts are insulated from funding cuts even in difficult fiscal circumstances. This can be achieved through concerted national actions and international cooperation.[8] Estimates have suggested that well over INR 40,000 crore will be needed annually to deliver all interventions, including food supplements and cash transfers.[9] These allocations will need to be split between the core programs – ICDS and NHM-delivering the POSHAN Abhiyaan interventions.

Ensuring that data are available for informed decision-making to monitor progress on programs, on use of services, on early warning signals for food and nutrition insecurity and malnutrition

It is important to understand the range of impacts of COVID-19 and associated policy actions on the drivers of malnutrition. This will help inform mitigation efforts. Effective data systems can help identify areas where urgent actions are needed on program coverage or on addressing different underlying or immediate determinants of malnutrition. Hence, it is important to retain nutrition as a development indicator and continue to invest in data systems. Periodic data-driven updates can support decision-makers with relevant information on the state of food and nutrition security as the COVID-19 crisis evolves. In particular, data systems must monitor program coverage, uptake and use as program responses shift, and must do so with a close eye on supporting rapid policy and program actions. This could be a tremendous opportunity to re-orient convergent action planning.


  Conclusions and the Way Forward Top


Although the human, economic, social, and emotional cost of this pandemic is colossal, it has underscored the importance of food and nutrition security in loud and unambiguous terms. Moving forward, a focus on the following areas will be necessary to strengthen actions to support India's progress on tackling malnutrition even in these unprecedented and extraordinary circumstances:

Understand the biological relationships between COVID-19 and malnutrition

To gain a better understanding of the epidemiological and biological relationships between COVID-19 and malnutrition, the demographic and nutritional assessments of COVID-19 patients are critical. Hence, clinical data gathering and research by the clinical community on how malnutrition affects COVID-19 progression and how COVID-19 affects malnutrition among those infected are essential.

Keep POSHAN Abhiyaan moving and adapt to a new normal of a COVID-19 sensitive POSHAN Abhiyaan

In view of the evolving life and work situation, with measures of physical distancing, it is important that POSHAN Abhiyaan keeps moving and adapts to a new normal. New innovative mechanisms need to be devised to keep reviews of POSHAN Abhiyaan ongoing and Social and Behavior Change Communication campaigns updated. Delivery of services needs to continue, although in ways that adequately address community fears and adopt safety measures of physical space distancing. It is crucial to keep financing for nutrition as a top priority for the overall agenda.

Strengthen cohesion among the nutrition community

Collective action and alliances among and across health and nutrition groups are even more necessary now than ever before. India's nutrition wins have come with hard work by many people over more than a decade. It is important to sustain this collaborative action and strong linkages among government, academia, private sector, development partners, national and state level institutions, civil society groups, CBOs (Women's Group, Youth Centre, SHGs such as JEEViKA with the objective of social and economic empowerment of the rural poor) and media to protect nutrition for India's human capital in the coming months and years.

Strengthen and deepen linkages with the research community

We cannot offer solutions on COVID-19 and nutrition without evidence building that moves alongside managing the crisis. It is essential for the research community to continue its quest of evidence building to support informed decisions.

In closing, India's nutrition journey is too important to be derailed by a crisis like COVID-19. The nutrition community in India must rally to support continued high priority attention to malnutrition in all its forms, to generate relevant evidence, and to support and engage all of society to urgently and adequately address malnutrition in the context of the COVID-19 pandemic. We have come too far to turn back now.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Naja F, Hamadeh R. Nutrition amid the COVID-19 pandemic: A multi-level framework for action. Eur J Clin Nutr 2020;74:1117-21.  Back to cited text no. 1
    
2.
The American Society for Nutrition. The Role of Nutrition in Supporting the Immune System Relative to Coronavirus (COVID-19). Available from: https://nutrition.org/the-role-of-nutrition-in-supporting-the-immune-system-relative-to-coronavirus-covid-19/. [Last accessed on 2020 Mar 20].  Back to cited text no. 2
    
3.
Centers for Disease Control and Prevention. People Who Are at Increased Risk for Severe Illness. Available from: https://rb.gy/bzjgf1. [Last updated on 2020 Jun 25].  Back to cited text no. 3
    
4.
Jayawardena R, Sooriyaarachchi P, Chourdakis M, Jeewandara C, Ranasinghe P. Enhancing immunity in viral infections, with special emphasis on COVID-19: A review. Diabetes Metab Syndr 2020;14:367-82.  Back to cited text no. 4
    
5.
Nutrition Connect. How India's Frontline Nutrition Programmes are Reinventing Themselves during the Lockdown. Available from: https://nutritionconnect.org/resource-center/indias-frontline-nutrition-programmes. [Last updated on 2020 Apr 27].  Back to cited text no. 5
    
6.
Roberton T, Carter ED, Chou VB, Stegmuller A, Jackson BD, Tam Y, et al. Early Estimates of the Indirect Effects of the Coronavirus Pandemic on Maternal and Child Mortality in Low- and Middle-Income Countries. Available from: https://ssrn.com/abstract=3576549. [Last accessed on 2020 May 09].  Back to cited text no. 6
    
7.
Joint Statement on COVID-19 Impacts on Food Security and Nutrition. Available from: https://www.worldbank.org/en/news/statement/2020/04/21/joint-statement-on-covid-19-impacts-on-food-security-and-nutrition. [Last accessed on 2020 Apr 21].  Back to cited text no. 7
    
8.
Statement by Mari Pangestu, Managing Director for Development Policy and Partnerships, the World Bank at the Virtual Meeting of G20 Agriculture Ministers. Available from: https://www.worldbank.org/en/news/speech/2020/04/21/statement-by-mari-pangestu-managing-director-for-development-policy-and-partnerships-the-world-bank-at-the-virtual-meeting-of-g20-agriculture-ministers. [Last accessed on 2020 Apr 21].  Back to cited text no. 8
    
9.
Chakrabarti S, Kapur A, Vaid A, Menon P. Achieving the 2025 World Health Assembly Targets for Nutrition in India: What Will it Cost? POSHAN Policy Note 2. New Delhi, India: International Food Policy Research Institute (IFPRI); 2017. Available from: http://ebrary.ifpri.org/cdm/ref/collection/p15738coll2/id/131083. [Last accessed on 2020 May 09].  Back to cited text no. 9
    


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