Thu07202017

Last updateThu, 15 Jun 2017 11am

You are here: Home | Agenda | Malnutrition | The wider effects of nutrition research: History of nutrition science and policy-Part 2

The wider effects of nutrition research: History of nutrition science and policy-Part 2

By Veena Shatrugna

The decision to focus on calories from cheap sources of food influenced many of independent India’s major policy decisions such as the shamefully low poverty line, a minimum wage to meet these low dietary requirements, a public distribution system limited to cereals, and high-input monoculture to produce these cereals. The combined results are seen in the undernutrition and catastrophic health profiles of Indians today. Micronutrient programmes are the natural extension of this policy

The consistent stand towards minimising costs in the interests of development priorities at the expense of sound nutritional practice on the one hand directly affects the manner in which policy pronouncements in adjacent domains are made. This section of the paper deals with the effects of nutritional science in the administrative definitions of poverty, calculation of minimum wages, agricultural policy and the nutritional supplementation schemes.

The poverty line

The decades between the 1950s and 1970s saw a group of committed, well-meaning administrators/intellectuals/scientists (almost invariably upper-class and upper-caste liberal) who saw it as their calling to solve the country’s problems. It would not be an exaggeration to say that the trajectory of development in India was determined by the intellectual hegemony and persuasive power of this group. Trained in the best western universities, they wielded the power of their disciplines to offer solutions to address the country’s problems. Whether it was C Gopalan, V M Dandekar, Nilakanth Rath, or M S Swaminathan, among many others, they looked for simple, upscaleable formulations at almost a laboratory level that could be applied across the nation. So a thesis like ‘adequate calories are the solution to the country’s food problem’ held an inherent appeal to both scientists and administrators, and of course bred a whole class of large-scale single-grain farmers (1). This was despite the fact that the foods eaten across the length and breadth of India consisted of vegetables, fruit, greens, wild berries, roots, tubers and leaves, mushrooms, eggs, lamb, pork, beef, birds, insects, fish, frog, small jungle animals like rabbits, snails and tortoises and many such sources. For purposes of calculations, calories sufficed. The focus on calories (and by reduction, on vegetarianism) also reflected the fact that they had no experience or understanding of the quality of life and culture among the marginalised.

The ’60s saw a crisis of agriculture, famine-like conditions and unmitigated poverty engulf most of India. The Ford Foundation commissioned a study on ‘Poverty in India’ in 1969-70 and asked V M Dandekar and Nilakanth Rath of the Indian School of Political Economy, Pune, to investigate the phenomenon. The report (Dandekar and Rath, 1971) tries to throw light on a whole range of issues related to poverty such as land policy, labour-intensive technology, questions of equity, etc. The section ‘Defining the Poor’ proposes what is now famous as the poverty line. Even today the government uses the Dandekar-Rath calculation to classify people in the so-called BPL (below the poverty line) category and APL (above the poverty line) category.

In the ’70s, the poverty line expenditure level was defined as that level of expenditure per capita per month, on all goods and services, of which the food component provided an energy intake of 2,400 calories per capita in rural areas and 2,100 calories per capita in urban areas. Since goods and services other than food were not defined or quantified in the poverty line calculation, a person would be considered above the poverty line even if 90% of his expenditure were on food alone. As Utsa Patnaik points out: “This is a very minimalistic definition of poverty since no norms are set for essential non-food items of spending such as on fuel for cooking and lighting, clothing, shelter, transport, medical care or education (Patnaik, 2006:10). According to Dandekar and Rath (1971:6), in 1960-61, an annual per capita consumer expenditure of Rs 170 was essential to give a diet adequate at least in respect of calories, and about one-third of the rural population lived on diets that were inadequate even in respect of calories. In the case of urban households, this figure was Rs 271, and nearly half the population lived on diets inadequate even in respect of calories. According to Patnaik, poverty line calculations in recent years have used the early expenditure figures, “simply adjusted upwards by using a price index while using an invariant 1973-74 consumption basket,” (Patnaik, 2005). She argues that if calculations were done keeping in view the changed consumption necessities and constraints over the years, the percentage of people falling below the poverty line would be far higher.

Be that as it may, what we should note in this saga of the poverty line is that the calorie, which was meant to be one index among many of nutrition, acquires a life of its own, and is used for measuring and setting the social and economic standards of a nation.

Minimum Wages Act, 1948

Another ‘progressive’ development in post-independence India was the attempt to fix minimum wages ‘scientifically’. India was one of the few countries which acknowledged the need for minimum wages, but the procedures adopted bear the imprint of the kind of administrative thinking being discussed in this paper. Recall that all attempts at formulating diets, RDA and calorie recommendations were made for different kinds of work (sedentary, moderate and heavy). Different kinds of work were identified and the calorie cost computed (for example, carry loads, dig a well or climb stairs) and then multiplied by the number of minutes or hours for which that work was done. However, there was no way of knowing what damage was done to the body when people did heavy work and consumed only cereals for calories without other nutrients like vitamins, minerals from milk, eggs, vegetables and fruits. Only one parameter was known -- the calorie cost of that work. There was no direct information on the diversity of foods needed for work. There was indirect information on the different aspects such as the amount of B-complex vitamins needed for 1,000 calories. Some of the studies were done on emaciated individuals. The calories needed for the underweight body to put on weight even as one carried out heavy work was nobody’s concern.

A Minimum Wages Act came into force in 1948, under which central and state governments were nominated as the appropriate agencies to 1) notify scheduled employment, and 2) fix/revise minimum wages. A Committee on Fair Wages was set up in 1948 to provide these agencies guidelines for wage structures. The work took over a decade. Their landmark recommendations set out the key concepts: living wage, minimum wages and fair wage besides setting out guidelines for wage fixation. Early discussions in these forums were not centred on food, much less on the concept of a balanced diet. The 1944 report (Aykroyd, 1944) came up for consideration in the 1950s.

However in 1957, the Indian Labour Conference rejected these recommendations for a balanced diet and accepted the simpler and seemingly more scientific recommendations based on calories alone. They suggested that the minimum wage should comprise the following:

  • Three consumption units for one earner.
  • Minimum food requirements of 2,700 calories per average Indian adult (now 2,400 calories).
  • Clothing requirements of 72 yards per annum per family.
  • Rent corresponding to the minimum area provided for under the government’s industrial housing scheme.
  • Fuel, lighting and other miscellaneous items of expenditure to constitute 20% of the total minimum wages.
  • Other parameters.

It took a trade union agitation leading to a litigation 40 years later to get a clause in the Supreme Court judgment reading, ‘children’s education, medical requirement, minimum recreation including festivals/ceremonies and provision for old age, marriage, etc, should further constitute 25% of the total minimum wage’ (Supreme Court of India in 1991 in the case of Raptakos Brett and Co vs its workmen).

Nutrition policy and agriculture

The emphasis on the RDA based on calories from cheap sources was one of the factors that fed into the large-scale investment in what is now called the Green Revolution in India. By the early-’60s, there was an ongoing collaboration between the National Institute of Nutrition and the Indian Council of Agricultural Research on the nutritive value of different varieties of foodgrain being studied for large-scale agriculture. M S Swaminathan, the noted agriculture scientist, had been inducted into the Nutrition Society of India (NSI) in 1967 and was privy to the discussion on nutrition problems, calories, RDA, cereals, etc. It would not be farfetched to surmise that the close relationship and collaborative efforts between agriculture and nutrition research were germane to Swaminathan’s work that led to the boost of high-input (of hybrid seeds, fertilisers and pesticides) cereal production that came to be called the Green Revolution.

Large-scale monoculture of rice and wheat in this strategy created the broad market conditions that limited the choice of purchasable food to cereals. By this time, food/cereal were being used as interchangeable terms in government discourse. Subsidised irrigation, fertilisers, pesticides and research for the large-scale production of cereals (rice and wheat), with financial and technical aid from the US, led to a more than doubling of the production of cereals from 98 million tonnes to over 230 million tonnes since the 1970s.

At about the same time, the public distribution system (PDS), designed for providing infrastructure for procuring, storing, transporting and distributing cheap/subsidised cereals to ward off hunger, had been set up throughout the country. Fixation of a procurement price and minimum support price by the government assured farmers some returns. The rice and wheat thus procured by the government were sold through the PDS network across the country. This subsidy and support for high-impact cereals production saw the decline of millets and even pulses in the follow-up to the Green Revolution. It is important to see that against such massive governmental support for cereal production and distribution, other dietary choices or strategies would have little chance to prove their economic viability.

It is my argument that this dietary monoculture that has been fostered and inculcated as the single and only choice by government policy has been instrumental in producing undernutrition and, as its consequence, the catastrophic health profiles we see today.

Nutrition programmes

In response to the large-scale distress among the rural and urban poor in the 1960s and 1970s, the government set up PDS outlets (ration shops) in the mid-1960s to provide subsidised cereals to the population. By 1990, these ration shops had covered over 80% of the population, and a large number of people, especially the poor, began depending on grain supplied by PDS outlets which, since it was subsidised, was often cheaper than the millets they produced. Investigations reveal that availability of food/cereal at affordable rates meant that people had some cash left to buy oil, pulses, and other food from the market. Every time the PDS was withdrawn, or became non-functional, it created unrest in those regions. The hunger for cereals increased with a supply and marketing system that led to cereals becoming the principal source of calories, and gradually the only food available to a large majority. It is significant that in recent years, many political parties have ridden to power on the promise of ‘two-rupee-per-kilo’ rice in the PDS.

In addition, food-for-work programmes were set up from time to time during the lean season or during times of drought. Cereals formed a part of the wages at these work sites. In every such welfare measure, the use of cereals to the exclusion of other dietary choices has led to the inevitable sharpening of the health deficit borne by the populations that are targeted by them. This is not to argue that such measures must be eliminated, rather that the foods that are distributed to the poor must be chosen not as an act of minimal charity, but as an important input that strengthens the life and viability of the severely disadvantaged.

Supplementary Nutrition Programme (SNP) and ICDS

Supplementary programmes to augment nutrition were also started in the ’60s. In addition to the PDS, the SNP actually provided cooked food to children. The extent of malnutrition had reached unacceptable levels of 60-80% among the poor, and especially among children. Scientists continued to argue that calorie deficiency was the major problem. The SNP was originally designed to be a cereal, pulse, oil and sugar mixture for children, but very soon a cereal-based 300-calorie food which provided 10 gm of protein (100 gm of any cereal provides 6-10 gm of protein anyway) began to be provided in these programmes. The idea was to use local foods (cereal/millet and pulses) for this programme. While it may be argued that nobody was aware at the time of the possible molecular damage caused by excess cereals, it is difficult to evade the manner in which scientists thought of implementing solutions for the poor that they under no circumstance would have accepted for themselves or for their own kind.

This food was distributed to pre-schoolers, especially in rural areas. It later included pregnant and lactating women. A large number of international agencies contributed supplies to the SNP. Cereals such as soya, corn, oil in different combinations were imported and fed to the children. This programme was later incorporated into the Integrated Child Development Services (ICDS) scheme in 1970 (the ICDS was an amalgamation of the SNP with education, health services, etc). Over time, the calculation of 300 calories per child resulted in the distribution of extremely poor quality broken wheat to children less than six years of age, in large parts of the country.

The programmes were kept alive only because of the huge network of government employees and contractors who made sure that ICDS money accrued to their businesses year after year. The programme was regarded officially as a failure. Reasons given were: the women did not care; the food was taken home and shared with siblings; the mother stopped giving the child other food turning ICDS food into a substitute, not a supplement.

It is not difficult to guess why the extent of malnutrition in children has stayed at over 50%. If the 300 calories had been derived from a variety of foods such as cereal, pulses, fat, milk, eggs, potatoes, fruits like bananas, nuts, oilseeds, communities would have some reason to make sure the programmes functioned. But cereal powders for which one had to take a child and stand in a queue did not attract mothers.

By the 1970s, it was also clear that advocating cereal diets would require countervailing ‘short-term measures’ in the form of nutrients such as Vitamin A and iron, folate, iodine, etc. Subsisting on cereals was naturally associated with large-scale anaemia (incidence of anaemia: 90% in pregnancy, 60-70% in children, and 50-60% in non-pregnant non-lactating women; even men were anaemic). The vicious cycle of anaemia with undernutrition in children and even adults cannot be addressed with either iron-fortified foods or iron tablets, or even kilograms of green leafy vegetables. It is known that a small amount of meat protein can help solve the problem of anaemia in a large number of cases, because meat proteins help absorb food iron. Vegetarian foods have high phytates, which inhibit iron absorption. There is also obviously a need for foods other than cereals for the poor such as milk, meat, eggs and fish, which have by now become illegitimate desires in the governmental perspective. With characteristic tunnel vision, public health measures addressed anaemia, which is not just a result of iron deficiency, but also due to deficiency of other nutrients such as protein, folic acid, B12, copper and many other nutrients, with a programme to distribute iron and folic acid to semi-starved pregnant women (and giving a smaller dose to children) in 1970. Today, this tunnel vision manifests itself in proposals and strategies to fortify wheat and rice with iron.

Insistence on vegetarian sources of protein followed up with programmes that supplied cereals invited large-scale and multiple nutrient deficiencies among populations. The problem of calcium requirement was simply addressed: by reducing the requirement from 1 gm (Aykroyd, 1944) to 400 mg (Gopalan and Narsinga Rao, 1968). The argument was that milk was expensive, and there were no other ‘cheap’ foods which could provide calcium. In any case there were no ‘biochemical’ parameters that showed deficiency, and green leafy vegetables could always be eaten. But most importantly, the common practice of chewing betel leaves smeared with slaked lime would increase calcium intake (Gopalan and Narsinga Rao, 1968). By now, the short heights were perceived as ‘normal’.

Again in the 1960s-1970s there were unacceptable levels of Vitamin A deficiency, manifesting as conjunctival xerosis, corneal ulcer and even blindness in children. It was suggested that massive oral doses of Vitamin A (in the form of drops) to children (2 lakh IU) once in six months would see us through this crisis.

By the 1990s, scientists have ‘discovered’ newer micronutrient deficiencies because of the cereal overload and virtual absence of any protective food in the diets of the poor. Technologies are now in place for the fortification of cereals (rice or wheat) with a range of micronutrients by the food and drug industry. Studies are also in place to push for multiple micronutrient fortification which include iron, zinc, iodine, Vitamin A, riboflavin, Vitamin B12, Vitamin D, etc.

Consequences

The nutrition and food policies of this country were set on this disastrous course in the ’50s and ’60s when ‘vegetarian sources of protein are adequate’ studies were followed by the ‘myth of the protein gap’ in the ’60s, and the 300 calories for children in the SNP. These steps were taken on the basis of strong and authoritative arguments by scientists of repute. The fixation of minimum wages, the shamefully low poverty line datum and the BPL and APL categories have remained unchallenged. The PDS/Green Revolution/food programmes further contributed to the problem because they dealt with only cereal. The molecular damage to the body when energy from cereals burns without the necessary nutrients such as vitamins and minerals is only now recognised. It is now known that excess cereal results in a particular kind of fat accumulation in Indians called triglyceride with abdominal obesity in men and women (Esmaillzadeh, Mirmiran, Azizi, 2005; Merchant et al, 2007). This is associated with early onset of diabetes or of what is called the metabolic syndrome. At even normal weights Indians have a higher fat content in their bodies especially around the abdomen. The only way of avoiding this is to increase muscle mass during childhood, and this means we must move away from the cereal trap.

Muscle mass

Many studies quoted above carried out in the ’40s and ’50s showed that children consuming milk grow tall as compared to children on rice diets. It is known that the only way to lay down more muscle mass is through consumption of milk or animal proteins such as flesh foods, meat extracts, eggs and perhaps some nuts in infancy and childhood (Rogers et al, 2006). Recent studies at the National Institute of Nutrition have confirmed the important role of milk proteins with abundant sources of nutrients like vitamins and minerals for increase in muscle mass, heights and weights of school children (Shatrugna et al, 2006).

Diabetes, blood pressure and cardiovascular diseases in Indians have been produced in epidemic proportions with the overemphasis on cereals in the diets of the poor. When short, lean children without adequate muscle mass put on weight as adults it is known that their weight increase happens due to fat increase (Kurpad, 2005; James, 2005). Some cynics even argue that short individuals should remain underweight if they have to escape these new diseases. It may be too late to reverse this body composition in our generation.

(Veena Shatrugna joined the National Institute of Nutrition (NIN), Hyderabad, as a medical graduate, and spent 34 years there, retiring as Deputy Director. Here, she was witness to the big debates raging on nutrition such as the Myth of Protein Gap, the Green Revolution and the National Nutrition Programmes. She has worked and published in the areas of nutrition in pregnancy, lactation, women's work, energy requirements, osteoporosis, and child nutrition and growth. She helped form Anveshi, a centre for women's studies in Hyderabad)

This article is excerpted from ‘The Career of Hunger: Critical Reflections on the History of Nutrition Science and Policy’, by Veena Shatrugna, in Towards a Critical Medical Practice: Reflections on the Dilemmas of Medical Culture Today, edited by Anand Zachariah, R Srivatsan and Susie Tharu on behalf of the CMC-Anveshi Collective, Hyderabad: Orient Blackswan; 2010. Reprinted with permission of the author and editors

Endnotes

1 In fact, the well-known mode of production debate in the ’70s was precisely on the extent to which this new group of large farmers represented the emergence of a new capitalist class in India. See Alavi (1990) for an influential review

 

References

Alavi, H. ‘India and the Colonial Mode of Production’. In Agrarian Relations and Accumulation: The ‘Mode of Production’ Debate in India, ed, U Patnaik (Bombay: Sameeksha Trust and OUP, 1990)

Aykroyd, W R. Report of the eleventh meeting of the Nutrition Advisory Committee of the Indian Research Fund Association held in New Delhi on March 27, 28, 1944

Aykroyd, W R. The Nutritive Value of Indian Foods and the Planning of Satisfactory Diets. Indian Research Fund Association, Health Bulletin No 23 (1937)

Aykroyd, W R and Krishnan, B G. ‘The Effect of Skimmed Milk, Soya Bean, and Other Foods in Supplementing Typical Indian Diets’. Ind Jour Med Res, 24. 1937

Cathcart, E P and Murray, A M T. 1931. Quoted in Nelson, M ‘The Distribution of Nutrient Intake Within Families’. Brit J Nut 55. 1986, 267-77

Dandekar, V M and Rath, N. Poverty in India. Bombay: Krishna Raj for EPW, 1971

Esmaillzadeh, A, Mirmiran, P, Azizi, F. ‘Whole-grain Intake and the Prevalence of Hypertriglyceridimic Waist Phenotype in Tehranian Adults’. Am J Clin Nutr 81, No 1. 2005. 55-63

Ferro-Luzzi, A, Sette, S, Franklin, M, and James, W P T. ‘A Simplified Approach to Assessing Adult Chronic Energy Deficiency’. Eur J Clin Nutr 46. 1992. 173-186

Food and Agriculture Organisation of the United Nations. Report of the 2nd Committee on Calorie Requirement. Rome, 1957

Gopalan, C. ‘Some Recent Studies in Nutrition Research Laboratories, Hyderabad’. Amer J Clin Nutr 23 No 1. 1970. 35-51

Gopalan, C and Narsinga Rao, B S. ‘Dietary Allowances for Indians’ (Special Report Series No 60). Indian Council of Medical Research. 1968

Gopalan, C, Sastri B V R, and Balasubramanian, S C. Nutritive Value of Indian Foods.Hyderabad: National Institute of Nutrition, Indian Council of Medical Research, 1989

Indian Council of Medical Research. ‘Recommended Dietary Intakes for Indians’. New Delhi: 1980

Indian Council of Medical Research, Special Report Series No 31, ‘Milk Substitutes of Vegetable Origin’. New Delhi, 1955

Indian Council of Medical Research, ‘Recommended Dietary Intakes for Indians’. 1980

James, W P T, Ferro-Luzzi, A and Waterlow, J C. ‘Definition of Chronic Energy Deficiency in Adults. Report of Working Party of IDECG’. Eur J Clin Nutr 42. 1988, 969-981

James, W P T. ‘The Policy Challenge Of Co-existing Undernutrition and Nutrition-Related Chronic Diseases’. Maternal and Child Nutrition 2005; 197-203

Kurpad, A V. ‘Body Composition and BMI Criterion for Indians’. NFI Bulletin 26, No 4. 2005. 1-4

League of Nations Report on the Physiological Bases of Nutrition. 1936. H2PHC

Merchant, A T, Anand, S S, Kelemen, L E, Vuksan, V, Jacob, R, Davis, B, Teo, K, Yusuf, S (for the SHARE SHARE-AP Investigators). ‘Carbohydrate Intake and HDL in a Multi-Ethnic Population’. Am J Clin Nutr 85. 2008. 225-230

Naidu, A N, Neela, J and Rao, N P. ‘Maternal Body Mass Index and Birth Weight’. Nutr News 12, 1991. National Institute of Nutrition, Hyderabad

National Nutrition Monitoring Bureau Report 1977, National Institute of Nutrition (ICMR), Hyderabad

National Nutrition Monitoring Bureau, Report of Urban Survey-Slums 1993-94. National Institute of Nutrition (ICMR), Hyderabad

National Nutrition Monitoring Bureau, Report of Second Repeat Survey 1996-97. National Institute of Nutrition (ICMR), Hyderabad

National Nutrition Monitoring Bureau Report 2006, National Institute of Nutrition (ICMR), Hyderabad

Nutrition Research Laboratories. Annual Report. Hyderabad, 1958

Patnaik, U. ‘How to Count the Poor Correctly Versus Illogical Official Procedures’. Social Scientist 33, No 7-8. 2005. 386-387

Patwardhan, V N. ‘Dietary Allowances for Indians, Calories and Proteins’. Indian Council of Medical Research, Special Report Series No 35. New Delhi. 1960

Reddy, V, Shekar, M, Rao, P, Gillespie, S. ‘A UN ACC/SCN Country Case Study: Supported by UNICEF’. Nutrition in India. 1992, 1-55

Rogers, I, Emmett, P, Gunnell, D, Holly, J, and the ALSPAC Study Team. ‘Milk as Food for Growth? The Insulin-like Growth Factor Link’. Publ Hlth Nutr 9, No 3. 2006. 359-68

Shatrugna, V, Ammini, A C, Tandon, N, Goswami, R, Gupta, N, Bhatia, E, Bhatia, V, et al. ‘Population-Based Reference Standards of Peak Bone Mineral Density of Indian Males and Females’. ICMR Multi-Centre Task Force Study, 1-34. New Delhi: ICMR, 2008

Shatrugna, V, Women’s Work And Its Impact On Child Health And Nutrition, National Institute of Nutrition (ICMR) 1993. Hyderabad

Shatrugna, V, Balakrishna, N, and Krishnaswamy, K. ‘Effect of Micronutrient Supplement on Health and Nutritional Status of School Children: Bone Health and Body Composition’. Nutrition 2006. S33-S39

Shetty, P S, James, W P T. ‘Body Mass Index, A Measure of Chronic Energy Deficiency in Adults’. Rowett Research Institute Aberdeen, UK. Food and Agriculture Organisation of the United Nations. 1994

Someshwar Rao, K. Review of Nutrition Surveys. Carried out in India. Indian Council of Medical Research, Special Report Series No 56. 1961

Venkatachalam, P S, Srikantia, S G, Mehta, G, and Gopalan, C. ‘Treatment of Nutritional Oedema Syndrome (Kwashiorkor) with Vegetable Protein Diets’. Ind Jour Med Res 44. 1956. 539-545

WHO Technical Report Series, 854. Physical status: The Use and Interpretation of Anthropometry. WHO. 1995

Infochange News & Features, July 2012