3

Chapter

Public Nutrition
And Health

Learning Objectives
After completing this chapter the learner will be able to:
zz understand the significance and scope of public nutrition.
zz have knowledge about the nutritional problems of public health
significance.
zz be acquainted with the government programmes that are in operation
to tackle important nutritional problems.
zz describe the role and functions of a public health nutritionist.
zz explain the knowledge and skills required for a career in public
health nutrition.

Introduction
In Class XI you studied the basic concepts of nutrition and health, physical
fitness and wellness. You must be aware of the importance of good
nutrition as the foundation and cornerstone of health. So what is significant
about the introduction of the word ‘public’ in this context? Let us find out.
You are already familiar with the definition of health given by the World
Health Organisation. The concept of public health refers to the collective
action taken by society to protect and promote the health of the whole
populations.

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 In Class XI, you were introduced to the terms undernutrition and
overnutrition. The mission in public health nutrition is to prevent both
undernutrition and overnutrition and to maintain optimal nutritional
status of the population.

Unit II - Nutrition, Food Science

Significance

And Technology
Why do we need to focus on this specific aspect in the field of nutrition?
Malnutrition is the underlying cause of at least 50 per cent deaths of
children under five years of age. The statistics for nutrition-related
problems in our country reveal an alarming situation:
zz Almost one-fifth of the infants born in India are low birth weight
babies i.e., they weigh less than 2500g or 2.5kg. Low birth weight
may have adverse effects throughout their growing years and may
have adverse implications even in adult life. Low birth weight may
even lead to child mortality.
zz There is widespread prevalence of growth retardation among pre-
schoolers (from socio-economically disadvantaged families) and almost
half the children suffer from mild and moderate under nutrition.
zz A large proportion of children (and adults) suffers from micronutrient
deficiencies in varying degrees of severity also known as hidden
hunger. The micronutrients of most concern are iron, zinc, vitamin A,
vitamin C, vitamin D, iodine, folic acid and B12.
If these problems are not controlled in time, they will not only affect
physical growth which may lead to smaller body stature in adulthood, but
may also affect mental and cognitive development. All of these, in turn,
can have negative impact on productivity and quality of life. The costs of
malnutrition are very high. Experts have estimated that productivity losses
are more than 10 per cent of lifetime earnings for individuals and 2-3
percent of gross domestic product for the nation. This clearly indicates that
if we tackle malnutrition, we can help India to develop, grow economically
and become a powerful nation.
India mostly faces the problem of under nutrition; however, the
problem of over nutrition is also on the rise. Gradually, over the years,
large numbers of persons have altered their dietary patterns and lifestyles.
With respect to lifestyle, people have become more sedentary, relying on
faster means of transportation, walking less and doing less amount of
physical activity. In large cities, even children do not play enough outdoor
games. Simultaneously dietary patterns have become less ‘healthful’. Food
choices have become less ‘healthy’ because processed foods, fast foods,
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 snacks, western type foods, e.g., burgers, pizzas, biscuits, chocolates,
cakes and pastries, soft drinks, even Indian mithais, samosas, etc. (that
Human Ecology and Family Sciences – Part 1

are high in energy, sugar, fat, salt and low in other nutrients and fibre)
are increasingly becoming part of the daily diet. At the same time, intake
of whole grains, pulses, vegetables and fruits has reduced. All these lead
to undesirable/inappropriate weight gain, overweight and obesity and
ultimately lead to diseases such as hypertension, heart disease, diabetes,
cancer, arthritis, among others. These diseases are non-communicable
and take their toll not only on the physical health but also on quality of
life, adding to the financial burden.
Thus India is said to face ‘the double burden of malnutrition’ i.e.,
coexistence of both undernutrition and overnutrition. Further, although
communicable diseases like smallpox have been controlled, newer ones like
HIV/AIDS and old ones like tuberculosis, hepatitis, malaria, are increasing
in prevalence. The ultimate consequences of these communicable diseases
are far worse for those who are not optimally nourished i.e., those who
are undernourished and those who have lower immunity due to obesity,
diabetes, HIV/AIDS, etc. This poses challenges for doctors, nutritionists
and the government in terms of treatment, control and prevention.
There is a tremendous need for a trained cadre of public health
professionals including public health nutritionists, to address and solve
these problems. Let us first acquaint ourselves with what is public health
nutrition.

Basic Concepts
What is Public Health Nutrition?

Public health nutrition is the field of study that is concerned with promotion
of good health through prevention of nutrition–related illnesses / problems
in the population, and the government policies and programmes that are
aimed at solving these problems. Public health nutritionists / professionals
use large scale, organised and multidisciplinary approaches to solve the
problems that affect the population i.e., large number of people for whom
group action is necessary. Therefore, this field is multidisciplinary in nature
and is built on the foundations of biological and social sciences. It differs
from other fields of nutrition e.g. clinical nutrition and dietetics, because
the professionals are required to address problems of the community /
public specially the vulnerable groups. Public Nutrition is a special body
of knowledge derived from the nutritional, biological, behavioural, social
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 and managerial sciences. It can also be described as the art and science of
promoting health and preventing diseases, prolonging life, through the
organised efforts/action of society.

Unit II - Nutrition, Food Science

A community is a specific group of people who share common
characteristics, e.g. a common language, exposed to similar conditions,
common lifestyle or the same health problem.

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Any professional in the field of public nutrition has to promote good
nutrition and /or to prevent nutritional problems, for which it is important
to identify the problem and its magnitude , understand how and why these
problems occur and then plan strategies and actions to implement them
and evaluate their impact.
In any society, nutritional problems are not just linked to food but to a
variety of interacting/interrelated factors at various levels which have been
summarised in Figure 3.1. While poverty is often the underlying cause,
the situation becomes worse when a substantial proportion of families do
not have access to basic amenities. Rural households have less access to
toilets. Poor sanitation results in loss of work days and further economic
loss. Further, considerable proportion of the population does not have
safe drinking water. Working days are lost each year due to water borne
diseases.
As shown in Figure 3.1, the factors related to nutritional problems range
from economic factors (availability of financial resources), agricultural
policy (production, price of various food stuffs), health care facilities/
services, their availability and access to the government policies, political
will and socio-cultural factors.
Nutritional Problems in India: It is important to have knowledge about the
nutritional problems in our country.
Let us discuss these in brief:
a) Protein- Energy Malnutrition(PEM) : Can be found in every society, even
in developed and industrialised countries, although the numbers are
fewer in the latter as compared to developing countries. It is caused
by inadequate food intake vis–a–vis the requirements, i.e., insufficient
intake of the macronutrients (energy and protein). Children are at
greatest risk although PEM can occur in adults especially the elderly,
as well as in some diseases e.g. T.B., AIDS, etc. It is assessed by
evaluating the anthropometric measurements (weight, height, head-
chest circumference, etc.).
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 Outcomes Malnutrition, disability and death
Human Ecology and Family Sciences – Part 1

Immediate
causes at 1. Inadequate or faulty dietary intake
individual 2. Disease or infections
level

1. Insufficient access to food

2. Poor maternal and child care practices
Underlying 3.
4.
Poor water / sanitation and hygiene
Inadequate health services and insufficient
causes at access to health services
Household 5. Inadequate and/or inappropriate knowledge
/ Family and discrimination against women, elderly
level and girl child.
6. Low level of education.

1. Quantity and quality of actual resources, e.g.,

human resources, financial and organisational
(existence of services and the way they are
operated and controlled).

Basic 2. Political, cultural, religious, economic and

social systems. This includes status of women,
Causes allocation of funds for programmes to solve
the problems, environmental degradation and
biodiversity.
3. Potential resources: environment, technology
and people.

Fig. 3.1: Factors Related to Undernutrition

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 A person is said to be underweight when his/her body weight is less
than adequate for his/her age. Stunting (short stature) is said to be
present when the height is less than adequate for age. When weight is

Unit II - Nutrition, Food Science

not adequate relative to height, it is termed ‘wasting’.

And Technology
Severe undernutrition due to deficiency of food and energy is termed as
‘marasmus’ and that caused by protein deficiency is termed ‘kwashiorkor’.
b) Micronutrient deficiencies: If the diet is deficient in energy and protein
content it is also likely to contain inadequate amounts of other nutrients
especially micronutrients viz. minerals and vitamins. The term “hidden
hunger” is used to refer to micronutrient deficiency. The deficiencies
of iron, vitamin A, iodine, zinc are of major public health concern. In
addition, there is growing concern about deficiency of vitamin B12,
folic acid, calcium, vitamin D and riboflavin. Some micronutrient
deficiencies of public health concern are described below:

(a) (b)

Victims of (a) Protein Energy Malnutrition and (b) Micronutrient Deficiency

Source: SIGHT and LIFE, Basel, Switzerland

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 (i) Iron-deficiency anemia (IDA): It is the most common nutritional
disorder in the world and is prevalent in both developed and
Human Ecology and Family Sciences – Part 1

developing countries. The vulnerable groups are women in

child–bearing age, adolescent girls, pregnant women and
school age children. IDA occurs when hemoglobin production is
considerably reduced and it results in low levels of hemoglobin
in blood. Symptoms depend on the rate of fall in hemoglobin.
Since hemoglobin is required for carrying oxygen in the body, any
physical exertion leads to shortness of breath (breathlessness
on slight exertion) and the person complains of fatigue and
may feel lethargic. Manifestations of IDA include general pallor,
paleness of conjunctiva of eyes, tongue and nail beds and soft
palate. In children, cognitive functions (attention span, memory,
concentration) are adversely affected.
(ii) Vitamin A deficiency (VAD): Vitamin A is necessary for mainten-
ance of healthy epithelium, normal vision, growth and immunity.
Deficiency of vitamin A results in night blindness which progresses
to complete blindness if corrective measures are not taken. Also,
there is less resistance to infection and growth may be adversely
affected. There is a vicious cycle between vitamin A deficiency
and infection. Vitamin A deficiency is the most common cause of
childhood blindness.

Vicious Cycle of vitamin A deficiency and infection

Vitamin A
deficiency

Increased Increased
losses of susceptibility
vitamin A to infection

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 (iii) Iodine deficiency disorders (IDD): Iodine is required for normal
mental and physical growth and development. IDD is an
ecological phenomenon, largely due to deficiency of iodine in
the soil. Some of the states in India where IDD is common are–
Jammu and Kashmir to Arunachal Pradesh in the Himalayan

Unit II - Nutrition, Food Science

belt, Andhra Pradesh, Karnataka, Kerala, Maharashtra and
Madhya Pradesh. The term ‘Iodine Deficiency Disorders’ refers
to a spectrum of disabling conditions that affect the health of

And Technology
humans, from fetal life through adulthood due to inadequate dietary
intake of iodine. Deficiency of iodine results in insufficient amount of
thyroid hormone which is synthesised by the thyroid gland.
Enlarged thyroid known as ‘goitre’ is the most common
manifestation of iodine deficiency in adults. In children it manifests
as cretinism. Iodine deficiency in adults during pregnancy has
several adverse effects specially resulting in mental retardation
and congenital abnormalities of the fetus. Unfortunately this
effect is irreversible. IDD is estimated to affect about 13 per cent
of the world’s population and about 30 per cent are at risk.

Strategies/intervention to tackle Nutritional Problems

As our former Prime Minister Dr. Manmohan Singh stated in one of his
speeches “The problem of malnutrition is a matter of national shame …… I
appeal to the nation to resolve and work hard to eradicate malnutrition in
5 years”. There is a need to adopt a multi-disciplinary approach to solve
nutritional problems. Government is making considerable efforts to solve
the problems. POSHAN Abhiyaan or the PM’s Overarching Scheme for
Holistic Nutrition was launched in Jhunjhunu, Rajasthan in March 2018.
It targets stunting, under-nutrition, anaemia (among young children,
women and adolescent girls) and low birth rate. It is meant to monitor
and review the implementation of all such schemes. Its large component
involves gradual scaling-up of interventions to all districts in the country
by 2022. The Ministry of Women and Child Development (MWCD) is
implementing POSHAN Abhiyaan in 315 districts in the first year, 235
districts in the second year and remaining districts will be covered in the
third year. Through robust multi-ministerial convergence mechanism and
other components POSHAN ABHIYAN strives to create the synergy. Some
direct short term interventions are: (a) Integrated Child Development
Services (ICDS )to cover all vulnerable children in the age group of 0-6
years and all pregnant and lactating mothers, (b) fortification of essential
foods (salt fortified with iodine), (c) production and popularisation of low
cost nutritious foods from indigenous and locally available raw material by
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 involving women in this activity and (d) control of micronutrient deficiencies
among vulnerable groups, namely deficiencies of iron, vitamin A, folic acid
Human Ecology and Family Sciences – Part 1

and iodine among children, pregnant women and nursing mothers by

supplementing these nutrients, distributing free tablets, etc.
Indirect policy instruments include long term strategies for achieving
national goals through indirect institutional or structural changes such
as: (a) ensuring food security i.e., improving availability of food, (b)
improvement in dietary patterns by ensuring availability of nutritionally
rich foods and (c) poverty alleviation for rural and urban poor through
employment generation schemes and public distribution system,
implementing land reforms, improving health and family welfare, prevention
of food adulteration, involvement of media, basic nutrition and knowledge,
monitoring of nutrition programmes, improvement of status of women,
education and literacy and community participation.
There are various strategies that can be used to combat public nutrition
problems. They are broadly classified as:
a) Diet or food-based strategies
b) Nutrient-based approach or medicinal approach
Diet or food-based strategies: They are preventive and comprehensive
strategies that use food as a tool to overcome nutritional deficiencies. They
can play an important role in preventing micronutrient deficiencies by
increasing the availability and consumption of micronutrient-rich foods.
One of the important advantages of this strategy is that it is sustainable
and will have long-term benefits. Other benefits are that they are cost-
effective, can be adapted to different cultural and dietary traditions and
very importantly they do not carry risk of overdose or toxicity which may
happen in case of nutrient–based / medicinal approach. Some important
food-based approaches include dietary diversification and modification,
horticulture interventions e.g., home gardening, nutrition and health
education, food fortification.
Nutrient-based or medicinal approach : In this approach nutrient
supplements are given to vulnerable groups i.e., those who are at risk
of deficiency and those who have deficiency. It is a short term strategy
particularly used for vitamin A, iron and folic acid in India. Supplementation
programmes are often expensive and there may be problems of coverage.
Key target groups are different for various nutrients.
Table 3.1 compares the two approaches. It must be remembered that
the long-term goal should be to shift away from supplementation towards
food-based approaches.

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 Unit II - Nutrition, Food Science
And Technology
Providing nutritious food Child with Vitamin A deficiency
Source: SIGHT and LIFE, Basel, Source: SIGHT and LIFE, Basel,
Switzerland Switzerland

Yellow, green & orange Vitamin A deficiency

fruits and vegetables are picture of eye
good source of Vitamin A

Iron and Folic acid drops

Weighing of a Child Counselling with mothers 55

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 Table 3.1: Different Interventions for Tackling Malnutrition

Intervention Appropriate for Advantages Challenges/

Human Ecology and Family Sciences – Part 1

Disadvantages
Medicinal or Nutrient Based
Nutrient Therapeutic Timely More costly than other
Supplementation treatment measures
Prevention Sustainability
programmes for Narrow scope of
specific nutrient and coverage
specific target groups

Food Based or Diet Based Strategies

Fortification Prevention (Universal Highly cost- Requires research
(fortifying food /For all) effective Participation of food
with nutrients) Wide coverage industry
Sustainable
Does not lead to
awareness in the
population about
the importance
of nutrition and
nutrients

Does not lead to

long-term dietary/
behavioral changes
Dietary Prevention (Universal Highly cost- Requires changes in
Diversification /For all) effective eating behaviour

Wide coverage Requires economic

Sustainable development to be
feasible
Provides many
micronutrients Requires change in
simultaneously agricultural policies

Improves food
security

Adapted from: Public Nutrition (Course Material) published by Indira Gandhi Open
University

Let us enlist the Nutrition programmes operating in our country:

1. ICDS: It is an outreach programme for early childhood care and
development, covering pregnant and nursing mothers and infants
56 and young children upto 6 years.

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 2. Nutrient Deficiency Control programmes, namely, National
Prophylaxis Programme for Prevention of Blindness due to Vitamin
A deficiency, National Nutritional Anemia Prophylaxis programme,
National Iodine Deficiency Disorder Control Programme,

Unit II - Nutrition, Food Science

3. Food Supplementation Programmes like the Mid-Day Meal Programme,
4. Food Security Programmes, namely, Public Distribution System,
Antodaya Anna Yojana, Annapurna Scheme, National Food for Work

And Technology
Programme, and
5. Self-employment and wage employment schemes.
Self-employment and wage employment are social safety net programmes.
Health Care: Health is a fundamental human right. It is the responsibility
of the government to provide adequate health care to the citizens. Health
care is not just medical care but it includes a multitude of services that
should help to promote, maintain, monitor or restore health. In India, health
care is provided at three levels : primary, secondary and tertiary. Primary
level is the first level of contact of the individual, family or community with
the health system. In our country, these services are provided through a
network of primary health centres (PHCs).
More complex health problems are resolved at the second level through
district hospitals and community health centres. Community health
centres function as the first referral level. Tertiary is the third and the
highest level of health care. It deals with the more complex health problems
that cannot be dealt with at the first two levels. Institutions at tertiary level
are medical college hospitals, regional hospitals, specialised hospitals and
All-India Institutes of Medical Sciences.

Scope
Role of Public Nutritionist: Nutrition is an important determinant
of health. The changing health scenario globally has increased the
challenges for public nutritionists. The public nutritionist (also called
community nutritionist), who is well trained and equipped in key areas,
is eminently suited to participate in all the strategies of health promotion
and prevention. The key areas include nutritional science, nutritional
needs throughout the life cycle, nutritional assessment, nutritional care,
food science, educational methods, mass media and communication
and programme management. A community nutritionist can work in the
following areas/situations.

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 (a) As a part of outreach programmes undertaken by hospitals for
prevention and promotion and education.
Human Ecology and Family Sciences – Part 1

(b) As a part of the national Integrated Child Development Services,

at different levels based on qualifications and expertise.
(c) At the government level as consultants, advisors, or in policy
making committees.
(d) In all developmental programmes of government, voluntary
organisations, NGOs and international organisations like UNICEF,
USAID, GAIN, Nutrition International, TATA Trust, IFPRI and
others are numerous other national and regional organisations.
(e) They can be involved with organisations who undertake large
scale feeding programmes for various target groups such as young
children, school children, adolescents, pregnant and lactating
mothers, elderly, challenged individuals.
(f) Nutritionists or school health counsellors in school health
programmes.
(g) They can be involved with corporate CSR programmes dealing
with food and nutrition security to vulnerable groups.
Besides this, there are avenues in teaching, research, entrepreneurship
with agencies involved in developing communication materials and
educational packages for those who have adequate and appropriate
training.

Activity 1
School to organise visit to Anganwadis (ICDS centres). Students can
interact with supervisor (if possible) or sevika, observe the activities
(if possible, be present when the food is distributed) and prepare a
power point presentation about the same.

Activity 2
School to organise an interactive session with medical officer /health
in charge of PSM dept / PHC / Municipal Corporation about the
problems of undernutrition and its the possible causes.

Activity 3
School to organise an exhibition on nutritional problems in India,
their causes, vulnerable groups and simple preventive measures.
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 Activity 4
Log on to the websites of WHO, UNICEF, Poshan Abhiyaan, Ministry
of Health and Family Welfare and Ministry of Women and Child

Unit II - Nutrition, Food Science

Development to learn more about their programmes and activities.

And Technology
Career Avenues
zz Community nutritionist in PSM departments of hospitals
zz Nutrition programmes of the government. e.g., ICDS, Food and
Nutrition Board
zz In voluntary organisations (regional, national and international)
as nutritionists
zz As consultants
zz Nutritionists or counselors for schools, industries, etc.
zz Teaching and academics
zz Research

Key Terms
Nutritional status, undernutrition, malnutrition, public health, public
nutrition, nutrition programmes, community health.

Review Questions
1. Explain the terms: Stunting, low birthweight baby, IDD, wasting,
‘double burden of malnutrition’, marasmus, kwashiorkor,
community.
2. Discuss the various strategies that can be adopted to combat public
nutrition problems.
3. What is public health nutrition?
4. What are the common nutritional problems facing India?
5. What are the consequences of IDA and IDD?
6. What is the scope of public health nutrition? List some of the career
choices in this area. 59

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 Practical 1
Human Ecology and Family Sciences – Part 1

Theme: Development and Preparation of Supplementary Foods for

Nutrition Programmes
Tasks: 1. Obtaining the prices of commonly consumed, locally
available foods
2. Planning of low-cost recipes for supplementary food for
preschoolers attending an Anganwadi.
3. Preparation of selected recipes
4. Evaluation of the prepared recipes
Purpose : This practical will provide insights to the students into planning,
costing and preparation of supplementary foods for preschoolers within a
given budget.

Conducting the Practical

1. Divide students into 4 groups

2. The groups should plan the recipes to provide selected nutrients as
follows:
Each group should plan 2 recipes and calculate the cost using the
price list. Plan should be made for 5 servings.
Group A: To plan recipes that will be good sources of energy and
protein
Group B: To plan recipes that will be good sources of iron
Group C: To plan recipes that will be good sources of vitamin A or
Beta carotene
Group D: To plan recipes that will be good sources of calcium
Note: Students are not required to calculate the nutritive
values/nutrient content of the recipes
A cost limit is to be given by the teacher (Not more than ` 5 per
serving).
3. Each group should identify the possible locally available food sources
for the specific nutrient for which they have to plan the recipes.
4. The planned recipes should be checked by the teacher and one
suitable recipe should be selected for preparation.
5. The product should be prepared in class and evaluated for (a) serving
size, (b) cost (c) suitability for preschoolers (d) appearance (e) taste (f)
acceptability by children.
6. Observations and comments should be recorded and suggestions
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given for improvement.

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