Five-step plan to prevent an impending nutrition famine during COVID-19 in India

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India’s isolation measures in response to COVID-19 are having a far-reaching impact and is among one of the largest initiatives globally to impose strict limitations on its 1.3 billion citizens. People with pre-existing vulnerabilities, marginalized communities, pregnant and lactating women (PLW), daily wage earners, migrant workers, and the elderly have been the hardest hit as the protective measures disrupt the economy.

To ease the effects of the pandemic, the national and state governments have announced extensive stimulus packages and policy measures. The national government on 12th May announced a $265 billion relief package aimed at injecting liquidity into the economy. The first tranche of $ 22.6 billion included several social protection measures such as payment of ex gratia amount to marginalized populations, increased wages for workers under the National Rural Employment Guarantee Act, doubling rations for three months, collateral-free loans to women’s Self Help Groups (SHGs), the inclusion of support to COVID-19 under Corporate Social Responsibility (CSR), and financial assistance to villagers through farmer cooperatives. These aid benefits are aimed to help more than 810 million Indians and are a step in the right direction.

In addition, integrating nutrition in the current policies will be fundamental to improving nutritional status and building immunity of the population, especially high need groups like PLW and children under 5 years of age. The WHO guidance on diet during the COVID-19 pandemic states that “good nutrition is crucial for health, particularly in times when the immune system might need to fight back”. India is already battling a high prevalence of malnutrition (Table 1). As India, in unison with the rest of the world, battles an evolving pandemic of unprecedented proportions, policymakers must be vigilant, agile, and innovative to halt our population from sliding into hunger and acute malnutrition due to the COVID-19 outbreak.

Table 1:

Source: Comprehensive National Nutrition Survey 2016-2018, Ministry of Health and Family Welfare Govt. of India.

We propose a five-point plan to put nutrition-sensitive policy measures in place to combat the adverse effects of COVID-19:

1. Increase budget and coverage for essentials

Many state and national governments have gone beyond the entitlement provisions under the National Food Security Act – 2013 to announce a stimulus package, the key elements of which are grain and pulses, and cash transfers to lower-income households. While this is a necessary and commendable step, a much stronger nutrition-sensitive hunger mitigation and food programming scheme is crucial. A basic, nutritious diet, recommended by the EAT-Lancet Commission, would cost at least INR 33.69 per day. Accounting for a family of 4, cash transfer of INR 500 per month would only satisfy a family’s requirement for approximately four days a month! Most states’ announcement of transferring an additional INR 1,000 only satisfies their requirement for an additional eight days. India has surplus food grains to weather the current crisis. Universal access and 3x more rations, irrespective of possession of ration cards, will be effective in addressing hunger including the 70 million poor households who lack an identification document.

2. Address malnutrition through dietary diversity, supplementation, and fortification:

Current food supplies through the Targeted Public Distribution Systems (TPDS) are predominantly comprised of grain and pulses. In the current situation where farm supply chains are expected to take at least four months to be restored, essentials such as vegetables, milk, and eggs, could be sourced directly from the farmers and made available in the open markets, supplied through public distribution systems and provided as weekly take home supplies to children and PLW. A few state governments such as the Telangana government have directed Anganwadi workers to provide eggs to mothers and children. Scaling such initiatives to a national level will help improve nutrition outcomes during the pandemic.
 
The honorable Prime Minister of India, in his address to the nation, ‘Mann ki baat’ on 25th August 2019, announced fortification of rice that is distributed to India’s poor through the public distribution systems, Integrated Child Development Services (ICDS) and mid-day meals. This would be the right time to implement the policy and improve access to fortified products including salt, edible oil, flour, rice, and milk. The aforesaid initiative is critical in the current scenario when nutrient consumption is bound to be erratic due to cash and food shortages.

3. Create awareness about nutrition practices:

Increasing evidence suggests that malnutrition increases susceptibility to infections including COVID-19. We, therefore, need to create awareness about better nutrition practices. The National Nutrition Mission (POSHAN Abhiyaan)’s Jan Andolan movement is a platform to engage in civil society and engage people to be committed to better nutrition. The Jan Andolan initiative can be utilized to implement a social behavior change campaign addressing food safety and feeding practices at the household level. Second, front-line workers can be empowered to halt the rise of malnutrition. They can be trained and equipped with behavior change communication equipment on nutrition care during pandemics. Empowering them with the right information and communication technology (ICT) equipment will enable them to spread information through digital platforms while following social distancing norms.

4. Incentivize farmers and small enterprises to produce nutrition-rich crops and food:

The following initiatives can improve the livelihoods of small-scale farmers and enterprises while improving access to nutrition. Incentivize smallholder farmers to produce nutrition-rich crops and staple foods and thus improving access to safe and nutritious diets across the value chain. Micro small and medium enterprises (MSMEs) can be motivated to produce and process nutritious and culturally appropriate foods using millets and legumes such as lentils, chickpea, groundnut, ragi which contain many nutrients and can store for long periods. They can also be prepared by women self-help groups authorized to prepare take-home rations and then the ICDS channel can distribute these foods to PLW and young children.


5. Harness technology for better nutrition:

India has a successful history of using technology to improve socio-economic and public health outcomes. For example, the Arogya Setu app, recently developed by the National Informatics Centre, uses technology to track coronavirus infections, thus providing a valuable tool in the fight against the pandemic. The government can similarly engage entrepreneurs to develop technologies to forecast the trend and pattern of disease burden in future months, rectify supply chain management of key food and nutrition supplies, revitalize already introduced software in public distribution systems to monitor food supplies.
 
Nutrition is a great equalizer. It can create the right environment to stimulate growth, economic development, and progress of an entire generation, thus propelling India on a path towards excellence. India has demonstrated early successes in managing the pandemic through strict isolation measures, innovative use of technology, and public health services. As we fight a pandemic of epic proportions, accounting for the nutritional needs of the world’s most vulnerable will not only give us the strength and immunity to fight COVID-19 but also save lives and give more babies the healthy start they deserve, irrespective of their socio-economic status.
 

The Role of Nutrition in the Immune System

Should we pay more attention? Part I of II

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As the coronavirus (COVID-19) is spreading rapidly across the globe, it is important to take note of the approaches that can help prevent and fight infections, particularly viral infections. Evidence already suggests that viral infections are one of the world’s greatest public health challenges (WHO, 2020). The World Health Organization (WHO) estimates seasonal influenza results in 3-5 million cases annually. Today we understand hygiene and social distancing play a key role in protecting yourself and others from contracting a virus while also slowing the spread of infections. Here are a few simple ways to reduce your risk to infections:

– Wash your hands regularly for 20 seconds with soap and water or alcohol-based hand rub.
– Cover your nose and mouth when you sneeze or cough with a disposable tissue or flexed elbow.
– Avoid close contact with people who are sick.
– Stay at home and self-isolate from others if you feel unwell.

Incorporating nutrition

Good nutrition is fundamental to improving immunity. The immune system is the body’s defense against disease and infection and it has long been established that several factors influence the function of the immune system including stress, sleep and nutrition (Song et al, 2019; Patel et al 2012 and Gombart et al 2020). The WHO guidance on diet, especially during the current pandemic states that “good nutrition is crucial for health, particularly in times when the immune system might need to fight back” (WHO, 2020). Providing a diet high in nutritious foods rich in vitamins and minerals supports optimal function of the immune system by providing antioxidants to slow damage of cells caused by free radicals (Lobo 2010) or assisting in T-cell production (Cohen 2017). 

Although, presently, we do not have data concerning nutritional factors in relation to the risk and severity of viral diseases such as COVID-19 the role of nutrition in immunity has been well established. For example, a study on the role of vitamin A in the treatment of measles in children found a reduced risk of mortality and pneumonia when vitamin A was administered over two days (D’Souza and D’Souza, 2002). The European Journal of Clinical Nutrition concluded that “Without adequate nutrition, the immune system is clearly deprived of the components needed to generate an effective immune response” (Marcos et al, 2003). Good nutrition is thus important in supporting an optimum immune system which can reduce the risk of viral infections (Beck and Levander, 2000).

It is now recognized that the complex, integrated immune system requires several micronutrients that have essential, often synergistic roles at every phase of the immune response (Gombart et al, 2020). In fact, even marginal deficiencies in certain nutrients have been shown to impair the immune system (Gombart et al, 2020). Micronutrients are believed to work collectively to support an optimum immune system. Based on a variety of systematic and clinical data, vitamins AB6, B12C, D, E, folate, zinc, iron, copper, and selenium (read our Vitamin and Mineral: a brief guide) are particularly important to boosting immune response.

The chart below identifies the role of these vitamins in immunity and shares recommended amounts and sources in the diet. In a forthcoming post, we will highlight the important minerals supporting the immune system and the work Sight and Life has achieved over the past 30 years to ensure access to vital nutrients, especially for children and women of childbearing age.

*Current advice on supplementation concludes that consuming a balanced diet provides all the necessary nutrition required but where there are challenges in meeting dietary recommendations, supplements are a useful addition in helping meet our nutritional needs (EUFIC, 2020).

*Please note these are approximate values and can vary based on recommended reference values employed.

Interested in learning more, read Part II HERE.

References

Beck,MA and Levander, OA (2000) Host Nutritional Status and Its Effect on a Viral Pathogen The Journal of Infectious Diseases, Volume 182, Issue Supplement_1, Pages S93–S96 [Online] Available at: https://academic.oup.com/jid/article/182/Supplement_1/S93/2191642) (Accessed on 1st April 2020)

Cohen S, Danzaki K, MacIver NJ. Nutritional effects on T-cell immunometabolism. Eur J Immunol. 2017;47(2):225–235. doi:10.1002/eji.201646423

Charan, J; Goyal JP; Saxena, D and Yadav, P (2012) Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. J Pharmacol Pharmacother.3(4): 300–303. [Online] Available at:http://www.jpharmacol.com/article.asp?issn=0976-500X;year=2012;volume=3;issue=4;spage=300;epage=303;aulast=Charan (Accessed on 30th March 2020)

D’Souza RM and D’Souza R(2002). Vitamin A for treating measles in children. Cochrane Database Syst Rev.(1) [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/11869601 (Accessed on 8th April 2020)

EUFIC (2020) Food and coronavirus (COVID-19): what you need to know [Online] Available at: https://www.eufic.org/en/page/food-and-coronavirus-covid-19-what-you-need-to-know (Accessed on 2nd April 2020)

Gombart AFPierre A and Maggini S (2020). A Review of Micronutrients and the Immune System-Working in Harmony to Reduce the Risk of Infection. Nutrients, Vol 12 (1) [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/31963293. (Accessed on 29th March 2020)

Gysin DV, Dao D, Gysin CM, Lytvyn L, Loeb M (2016). Effect of vitamin D3 supplementation on respiratory tract infections in healthy individuals: a systematic review and meta-analysis of randomized controlled trials. PloS one.11(9).[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025082/ (Accessed on 1st April 2020)

Hemilä H, Louhiala P (2013). Vitamin C for preventing and treating pneumonia. Cochrane database of systematic reviews (Issue 8) [Online] Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005532.pub3/abstract (Accessed 2nd April 2020)

Song, H  Fall,K; Fang,F; Erlendsdóttir,H; Lu, D; Mataix-Cols, D; Fernández de la Cruz, L;  D’Onofrio; BM; Gottfreðsson,M; Almqvist, C; Unnur A Valdimarsdóttir (2019) Stress related disorders and subsequent risk of life threatening infections: population based sibling controlled cohort study. BMJ 367: l5784 [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812608/ (Accessed of 7th April 2020)

Charan, J; Goyal JP; Saxena, D and Yadav, P (2012) Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. J Pharmacol Pharmacother.3(4): 300–303. [Online] Available at:http://www.jpharmacol.com/article.asp?issn=0976-500X;year=2012;volume=3;issue=4;spage=300;epage=303;aulast=Charan  (Accessed on 30th March 2020)

Lee, GY and Nim Han, S (2018) The role of Vitamin E in Immunity. Nutrients 10(11): 1614 [Online] Available at :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6266234/ (Accessed on 2nd April 2020)

Lobo V, Patil A, Phatak A, Chandra N. Free radicals, antioxidants and functional foods: Impact on human health. Pharmacogn Rev. 2010;4(8):118–126. doi:10.4103/0973-7847.70902

Marcos, A., Nova, E. & Montero, A (2003). Changes in the immune system are conditioned by nutrition. Eur J Clinical Nutrition 57, S66–S69 [Online] Available at: https://www.nature.com/articles/1601819 (Accessed on 7th April 2020)

Meydani SN1, Han SN, Wu D. Vitamin E and immune response in the aged: molecular mechanisms and clinical implications. Immunol Rev.205pp:269-84.[Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/15882360 (Accessed on 8th April 2020)

Mikkelsen K., Apostolopoulos V. (2019) Vitamin B12, Folic Acid, and the Immune System. In: Mahmoudi M., Rezaei N. (eds) Nutrition and Immunity. Springer, Cham

Moriguchi S and Muraga M (2000) Vitamin E and immunity. Vitam Horm.(Vol 59) pp:305-36 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/10714244  (Accessed on 1st April 2020)

Patel SRMalhotra AGao XHu FBNeuman MIFawzi WW (2012) A prospective study of sleep duration and pneumonia risk in women. Sleep1;35(1):97-101 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/22215923(Accessed on 8th April 2020)

Rall LC  and Meydani SN (1993) Vitamin B6 and immune competence. Nutr Rev. Vol 51(8):217-25 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/8302491 (Accessed on 2nd April 2020)

Tamure; J; Kubota,K; Murakami H; Sawamura, M; Matsushima T; T;Tamura, Saitoh, T; Kurabayshi, H and Naruse, T(1999)  Immunomodulation by vitamin B12: augmentation of CD8+ T lymphocytes and natural killer (NK) cell activity in vitamin B12-deficient patients by methyl-B12 treatment Clin Exp Immunol Vol 116(1): 28–32.[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1905232/ (Accessed on 13th April 2020)

WHO (2020) Food and Nutrition tips during self-quarantine [Online] Available at: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/food-and-nutrition-tips-during-self-quarantine  (Accessed on 2nd April 2019)

World Health Organization (2020) WHO launches new global influenza strategy [Online] Available at: https://www.who.int/news-room/detail/11-03-2019-who-launches-new-global-influenza-strategy (Accessed on April 7th2020)

WHO (1998) Vitamin and mineral requirements in human nutrition Second edition. https://apps.who.int/iris/bitstream/handle/10665/42716/9241546123.pdf?ua=1

Zhiyi Huang;Yu Liu;Guangying Qi; David Brand and Song Guo Zheng (2018) Role of Vitamin A in the Immune System. J Clin Med  7(9): 258. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162863/(Accessed on 28th March 2020)

Zhou, Jian MD*; Du, Juan MD*; Huang, Leting MD; Wang, Youcheng MD; Shi, Yimei MD; Lin, Hailong MD(2018) Preventive Effects of Vitamin D on Seasonal Influenza A in Infants – A Multicenter, Randomized, Open, Controlled Clinical Trial The Pediatric Infectious Disease Journal Vol 37 (8) pp 749-754 [Online] https://journals.lww.com/pidj/fulltext/2018/08000/Preventive_Effects_of_Vitamin_D_on_Seasonal.5.aspx (Accessed on 2nd April 2011)

Spotlight: Gratitude to frontline workers at the time of coronavirus

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At nearly six months pregnant, Vidyarani learned that her neighborhood anganwadi center was closing due to the coronavirus (COVID-19) control measures. She depends on the anganwadi for a daily hot cooked meal to feed herself and her two-year-old daughter. Adding to her growing concerns, the lockdown caused her husband to lose his job. 

Anganwadis, or courtyard shelters, are primary childcare centers providing basic health care activities and nutritious meals for families while also serving as a pre-school for young children. Across all states in India, anganwadis serve either hot cooked meals or provide monthly rations that can be cooked at home. The Telangana state government, for instance, serves approximately half a million hot cooked nutritious meals daily to pregnant and lactating women through the anganwadis. As a part of this program, all beneficiaries also receive one egg every day. Here at Sight and Life, we know the importance of including eggs in a diet.

As COVID-19 quickly spreads around the globe, India has enforced a nation-wide lockdown to contain the disease creating unprecedented challenges for people like Vidyarani and their families. In addition to the closure of primary schools and anganwadi centers, children in rural India are now not attending school and therefore have to do without their guaranteed school meal, potentially worsening an already “severe” malnutrition problem in India. Even though the government has ordered state authorities to ensure provision of take-home rations and cash allowance during the lockdown, efforts to tackle acute malnutrition could still take a hit. It is in times like these that India’s frontline workers are making sure that no one in their communities goes hungry. Many anganwadi teachers are going door-to-door to deliver their weekly rations of rice, lentils, oil and eggs to beneficiaries.

COVID-19 Essentials Delivery

In this photo, tweeted by the Women and Child Development Ministry of Telangana, an anganwadi teacher delivers take-home rations including eggs to the homes of lactating mothers in the tribal region of Mulugu district via her scooter. Women like Vidyarani and their families are grateful for these workers delivering essential food items.