Learn — Malnutrition & national nutrition programmes

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Food-related diseases

Food-related diseases are the disorders that arise directly out of what is eaten or not eaten: the deficiency diseases of an inadequate or monotonous diet, the toxic diseases of contaminated or adulterated food, and the chronic diseases of dietary excess. They matter in Indian practice because most of them are diseases of a single missing nutrient in a cereal-dominated diet, so they are diagnosed from the diet history at the bedside and prevented by advice, fortification and a supplementation programme rather than by a hospital admission.

Protein-energy malnutrition takes two forms that must be told apart: kwashiorkor, where energy is roughly adequate but protein is not, gives bilateral pitting oedema, a flaky-paint dermatosis, sparse discoloured hair with the flag sign, a moon face, an enlarged fatty liver, apathy and a lost appetite; marasmus, where both energy and protein are deficient, gives extreme wasting with loss of subcutaneous fat and muscle, an old-man facies, no oedema, and a child who is alert and hungry.
Severe acute malnutrition is defined objectively, not by appearance: a weight-for-height more than three standard deviations below the median, or a mid-upper arm circumference under 11.5 cm in a child of 6 to 59 months, or bilateral pitting pedal oedema, any one of which is sufficient.
The single-nutrient diseases follow the staple: beriberi from thiamine deficiency on a polished-rice diet, in a wet cardiac form and a dry neuropathic form; pellagra from niacin deficiency on a maize diet, in which niacin is bound as unavailable niacytin and tryptophan is scarce, giving dermatitis, diarrhoea and dementia; scurvy from vitamin C deficiency with bleeding gums and perifollicular haemorrhages; rickets from vitamin D; nutritional anaemia from iron, folate or B12; and goitre and cretinism from iodine.
The toxic food diseases asked in Indian papers are lathyrism from prolonged consumption of kesari dal (Lathyrus sativus), whose neurotoxin causes a spastic paraparesis of young men; epidemic dropsy from argemone oil adulterating mustard oil, causing oedema, erythema and glaucoma; and aflatoxin from Aspergillus flavus growing on damp groundnuts and maize, which damages the liver and causes hepatocellular carcinoma.
Bacterial food poisoning is distinguished by its incubation period: vomiting within 1 to 6 hours of a milk or meat dish points to the preformed toxin of Staphylococcus aureus, vomiting within hours of reheated rice to the emetic toxin of Bacillus cereus, diarrhoea and cramps at 8 to 22 hours from meat dishes to Clostridium perfringens, and fever with diarrhoea at 12 to 36 hours to Salmonella; botulism from home-canned or preserved food is different in kind, giving a descending flaccid paralysis with ptosis, diplopia and respiratory failure.
The water- and food-borne infections that produce outbreaks — cholera, typhoid, hepatitis A and E, amoebiasis and giardiasis — are prevented by safe water, hand washing, cooking food thoroughly, keeping cooked food covered and hot, and excluding food handlers who are ill, and any cluster of cases is notified rather than treated bed by bed.
Diseases of dietary excess are now the larger burden: obesity, type 2 diabetes, hypertension, dyslipidaemia and fatty liver, driven by refined cereals, sugar-sweetened drinks, trans fats and inactivity, with the Asian Indian body mass index cut-offs of 23 for overweight and 25 for obesity applied rather than the international ones.
Prevention runs on four lines that a nurse teaches directly: dietary diversification, fortification (iodised and double-fortified salt, fortified oil and wheat flour), supplementation programmes such as vitamin A, iron-folic acid and zinc, and food safety and hygiene, all supported by the Anganwadi Services of Mission Saksham Anganwadi and Poshan 2.0 (formerly ICDS) and by PM POSHAN (formerly the mid-day meal scheme).

POSHAN Abhiyaan and Mission Poshan 2.0

POSHAN Abhiyaan (Prime Minister's Overarching Scheme for Holistic Nourishment), the National Nutrition Mission, is the flagship of the Ministry of Women and Child Development launched on 8 March 2018 at Jhunjhunu in Rajasthan to bring down stunting, underweight, low birth weight and anaemia by fixed yearly targets through convergence, technology and a people's movement rather than through a new feeding scheme. Mission Poshan 2.0, announced in the 2021 budget, merged it with the supplementary nutrition of ICDS and the Scheme for Adolescent Girls into the Saksham Anganwadi and Poshan 2.0 umbrella, so that the programme the anganwadi delivers today is one scheme with one tracker.

Targets set for 2017-18 to 2021-22: a fall of 2 percentage points a year each in stunting, underweight and low birth weight among children under six, and of 3 percentage points a year in anaemia among children, adolescent girls and women — with the headline aim of bringing stunting down from 38.4 per cent (NFHS-4) to 25 per cent by 2022.
The strategy stands on five pillars: ICT-based real-time growth monitoring (first the ICDS-CAS app, since 2021 the Poshan Tracker on every anganwadi worker's smartphone), convergence of the ministries whose work touches nutrition, a Jan Andolan or community movement, incentives to states and workers for reaching targets, and capacity building of the frontline through incremental learning.
The Jan Andolan is scheduled: Poshan Maah every September and Poshan Pakhwada in March–April, with community events such as the annaprashan (first complementary feed at six months), godbharai (pregnancy) and growth-monitoring days that make weighing a child a public act rather than a private one.
The first 1000 days — conception to the second birthday — is the window the mission protects, so its interventions are the antenatal package, early and exclusive breastfeeding, complementary feeding from six months, growth monitoring, immunisation, deworming, iron and folic acid, and water and sanitation, delivered together at the anganwadi and the village health, sanitation and nutrition day.
Mission Poshan 2.0 (2021-22 onwards) added the treatment of severe and moderate acute malnutrition at the community level, an emphasis on maternal nutrition and infant and young child feeding, wellness through AYUSH practices, Poshan Vatikas (nutrition gardens at anganwadis), millets in the take-home ration, and fortified rice, and it counts every beneficiary on the Poshan Tracker.
NFHS-6 (2023-24) is the latest report card: stunting 29.3 per cent, wasting 19.0 per cent, underweight 31.8 per cent (NFHS-5, 2019-21: 35.5, 19.3 and 32.1). NFHS-6 does not report anaemia, so the latest survey figures are still NFHS-5's 67.1 per cent of children aged 6 to 59 months and 57 per cent of women aged 15 to 49 — between NFHS-4 and NFHS-5 stunting and underweight fell but anaemia rose, which is why anaemia has its own strategy under Anemia Mukt Bharat Abhiyaan.
The nurse's part is the same at every level: weigh and measure on time, plot on the WHO chart, enter the Poshan Tracker, refer the red-zone child, counsel the mother at the first 1000-day contacts, and make the monthly nutrition day a real event; the anganwadi worker records, the ANM and ASHA follow up.

PM POSHAN (Mid-Day Meal) scheme — norms and coverage

PM POSHAN (Pradhan Mantri Poshan Shakti Nirman) is the Ministry of Education's scheme that serves one hot cooked meal a day to every child in classes I to VIII of government and government-aided schools, and since 2021 to pre-primary children in Bal Vatikas, to improve nutrition, enrolment, attendance and retention at the same time. It is the renamed Mid-Day Meal Scheme, the world's largest school feeding programme, and the exam asks its dates, its energy and protein norms per meal and the food-grain quantities behind them.

History in dates: Madras Corporation fed school children from 1925 and Tamil Nadu ran a state scheme from the 1960s; the National Programme of Nutritional Support to Primary Education began on 15 August 1995 with a dry ration of 3 kg of grain a month; the Supreme Court ordered cooked meals in November 2001; upper primary classes were added in 2007, when the name Mid-Day Meal Scheme was adopted; and in September 2021 it became PM POSHAN for 2021-22 to 2025-26.
Nutritional norms per child per school day: primary (classes I to V) 450 kcal and 12 g of protein, upper primary (classes VI to VIII) 700 kcal and 20 g of protein — the protein figure is the one most often asked.
Food norms behind the calories: 100 g of food grain (rice or wheat) for primary and 150 g for upper primary, with 20 g and 30 g of pulses, 50 g and 75 g of vegetables, and 5 g and 7.5 g of oil respectively; fortified rice is now supplied through the scheme, and states may add milk, eggs or fruit from their own funds.
The meal is served in the school on every school day, cooked in a school kitchen or by a centralised kitchen or self-help group, tasted by a teacher or parent before serving, with a hygiene chain from grain storage to hand-washing before the meal; deaths from contaminated meals have made the tasting register and the storage of oil and grain away from pesticides a matter of law.
Coverage is about 11.2 crore children in about 10.4 lakh schools (2025), funded by the Centre and the states in a 60:40 ratio (90:10 for the north-eastern and Himalayan states, 100 per cent in union territories without a legislature), with the Centre supplying the grain through the Food Corporation of India.
Add-ons that ride on the meal: school health check-ups, deworming on National Deworming Day, weekly iron and folic acid under Anemia Mukt Bharat, school nutrition gardens, Tithi Bhojan (community-contributed special meals), and social audit by the school management committee, which also monitors attendance against the meal register.
The evidence the scheme rests on is that a hot meal raises enrolment and attendance of girls and the poorest children, reduces classroom hunger, and levels caste and class at the shared plate; its nutritional effect is limited to what one meal a day can do, which is why it sits beside ICDS, Poshan 2.0 and the iron programme rather than replacing them.

Diet surveys and community nutrition surveillance

A diet survey measures what a family or a population actually eats so that intake can be compared with the recommended allowances and the gap named, while nutritional surveillance is the continuous collection of indicators — growth, anaemia, birth weight, diet — that lets a district act before a food crisis or a programme failure shows up as dead children. The two together are the assessment half of community nutrition: the anthropometry and clinical signs on the paediatric notes tell you a child is malnourished; the diet survey tells you why.

The weighment method is the reference for family surveys: every raw food is weighed before cooking, usually for seven consecutive days, cooked food is measured, and intake per consumption unit is calculated; it is accurate but slow, expensive and intrusive, which is why it is used for research rather than routine.
The 24-hour recall is the workhorse: the respondent describes everything eaten in the previous day, quantities are estimated with standard cups, spoons and katoris, and intake is converted with food composition tables; it is quick and cheap but depends on memory and on one day being typical, so it is repeated or combined with a food frequency questionnaire for habitual intake.
Other methods: the diet history (usual pattern over weeks), the food frequency questionnaire (how often each food is eaten), the inventory or food-list method (stocks and purchases over a period), the duplicate-sample chemical analysis (a copy of every meal is analysed in the laboratory — the most accurate and least practical), and at national level the food balance sheet, which divides the food available in the country by its population.
Intake is expressed per consumption unit: a sedentary adult man is 1 unit, and everyone else is a fraction of him — an adult woman about 0.8, a child of 1 to 3 years about 0.4 — so that a family of different ages can be compared with one reference; adequacy is then judged against the ICMR-NIN allowances, and a cereal-pulse diet with less than 100 g of vegetables a day is the commonest gap found.
The National Nutrition Monitoring Bureau, set up by ICMR at the National Institute of Nutrition in 1972, ran the repeat diet and nutrition surveys of rural India in ten states for four decades and is the source of the classic Indian intake figures; the National Family Health Survey (NFHS-5, 2019-21) now supplies the anthropometry, anaemia and infant feeding indicators, and the Comprehensive National Nutrition Survey (2016-18) added biochemical markers in children and adolescents.
Surveillance indicators a nurse feeds: monthly weights and the growth chart at the anganwadi entered on the Poshan Tracker, mid-upper arm circumference screening, the proportion of low-birth-weight babies in the sub-centre register, haemoglobin at antenatal and school contacts, and the ICDS monthly progress report — each becomes a warning when it moves in the wrong direction for two or three months.
Indirect indicators tell the same story at population scale: the infant and under-five mortality rates, the prevalence of low birth weight, and food prices and rainfall — the early warning of a nutritional emergency comes from the market and the rain gauge before it comes from the clinic.

Food fortification, adulteration and food safety — FSSAI and the +F logo

Food fortification is the deliberate addition of micronutrients to a widely eaten staple — iodine and iron to salt, vitamins A and D to oil and milk, iron, folic acid and vitamin B12 to rice and wheat flour — at levels set by the Food Safety and Standards Authority of India, whose +F logo marks a fortified food; food adulteration is the opposite act, the addition of a cheaper, harmful or inert substance to food for profit, and food safety is the law and the kitchen practice that stand between the two. The nurse meets all three in the same community: the fortified rice in the school meal, the argemone oil behind an outbreak of dropsy, and the food handler with unwashed hands.

Fortification standards under the Food Safety and Standards (Fortification of Foods) Regulations 2018: salt with iodine, or iodine plus iron as double-fortified salt; edible oil and milk with vitamins A and D; wheat flour and rice with iron, folic acid and vitamin B12 (rice through fortified rice kernels blended at 1 in 100); a compliant product carries the +F logo, and the public system — the public distribution system, ICDS and PM POSHAN — now supplies fortified rice throughout the country.
Fortification works because it needs no change of behaviour and reaches the poor through the food they already buy; iodised salt is the proof, having taken India from endemic goitre to near-elimination in a generation. Its limits are that it cannot replace a diverse diet and that iron fortification needs the deficiency to be iron deficiency.
Common adulterants and the simple tests: argemone (prickly poppy) oil in mustard oil, which causes epidemic dropsy and is detected by the red-brown colour with nitric acid; metanil yellow in turmeric, dal and sweets, detected by the pink-red colour with hydrochloric acid; kesari dal (Lathyrus sativus) mixed into pulses, the cause of lathyrism; starch in milk, which turns iodine blue; chalk or brick powder in flour and chilli, which settle in water; and lead chromate, rhodamine B and Sudan dyes in spices.
The law: the Prevention of Food Adulteration Act of 1954 was replaced by the Food Safety and Standards Act 2006, under which the Food Safety and Standards Authority of India (FSSAI, 2008) sets standards and licenses or registers every food business; the state Food Safety Officer samples and prosecutes, and the Eat Right India movement, front-of-pack labelling and the ban on trans fat above 2 per cent in oils are FSSAI initiatives.
The WHO five keys to safer food are the kitchen rules a nurse teaches food handlers and mothers: keep clean (hands, surfaces, pests), separate raw and cooked, cook thoroughly (above 70 degrees in the centre), keep food at safe temperatures (not in the danger zone between 5 and 60 degrees, and not out for more than two hours), and use safe water and raw materials.
Milk safety rests on pasteurisation — the holder method at 63 degrees for 30 minutes, the high-temperature short-time method at 72 degrees for 15 seconds, and ultra-high temperature at about 135 degrees for a few seconds — proven by the phosphatase test; food handlers are examined before employment and periodically, excluded while they have diarrhoea, jaundice, skin sepsis or a sore throat, and taught hand-washing after the toilet and before handling food.
The toxic food diseases themselves — lathyrism, epidemic dropsy, aflatoxicosis, bacterial food poisoning by incubation period — are on the food-related diseases note; this note carries the prevention: the test that finds the adulterant, the officer to inform, and the sample to preserve.

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