Gratified by the suggestions and critiques of our earlier article of July 19: ‘Arming India’s poor against the pandemic’, we offer an updated Part 2 here. The very first update is the comprehensive and authoritative paper by C. V. Harinarayan and H. Akhila, titled: “Modern India and the tale of twin nutrient deficiency- calcium and vitamin D- nutritional trend data of 50 years-retrospect, introspect and prospect”, that has appeared in the journal Frontiers in Endocrinology, August 9, 2019 https://doi.org/10.3389/fen-do.2019.00493. Dr. Harinarayan has been involved in this area for decades, conducting trials and comparing levels of calcium and Vitamin D in rural, urban, poor, not-so-poor and well-to-do persons in Tirupati, Karnataka and elsewhere, with rigour. In the section on Prospect in this paper, the authors have recommended several steps that should be taken to propagate them through schools and colleges, and social media using cell phones, TV and radio, how nutritional deficiencies can be overcome through the help of expert groups and through supplementation on a mass scale. (I recommend that this important paper be read by all). While many of these suggestions are already being practised, there is need for even more.
Genetics and vitamin D deficiency
On an aside, and interestingly, while they (and Selvarajan et al. in 2017, too) ask why a sun-blessed nation still exhibits vitamin D deficiency, we notice from other reports that a similar deficiency occurs among people of the Indian sub-continental origin settled in Great Britain (for example, Patel et al., International Journal of Cardiology, 2013, 2172-76 <doi:10.1016/j.ijcard.2012.05.081>. This has made some wonder whether any genetic factors are involved. (Light falling on the skin produces a precursor molecule, which is processed in the cells of the organs to make vitamin D, and if this becomes faulty due to any genetic/metabolic error, deficiency might arise). One Roger Bouillon writes in Nature Reviews Endocrinology, 13, 464-79, 2017, that there might be at least four genetic variants. It would be worthwhile for Indian geneticists to take up this possibility in our deficient populations.
Harinarayan and Akhila point out that calcium levels are deficient not just in India’s poor, but even among the well-to-do. The data provided by the National Nutrition Monitoring Board (NNMB) reveal that over the last 50 years, the calcium (Ca++) levels in average Indian populations has plummeted from 700 units per day to 300-400, (far below the normal, needed level of 800-1,000), again a puzzle for the top country in the world which produces the maximum amount of milk per day! Milk products are rich sources of calcium. This leads to weaker bones and diseases like rickets. Ca++ is also needed by vitamin D for its action. Thus, both sub-normal calcium and vitamin D is a double whammy! The paper thus suggests, in the Prospects section, that while supplementation of these two is essential for a healthy India, we should also have all schools have their students stand in sunlight for 20-30 minutes daily, and encourage physical exercise and games for an hour per day. These will be in addition to the daily mid-day meals that they offer to all students (and teachers).
Fighting hidden hunger
The Central and State governments, many NGOs and public spirited individuals have been helping the poor by offering free wheat/rice plus pulses. In addition, they have been offering highly subsidized food items like sugar, milk and some vegetables, but no cooked food. Nutrition experts across India have emphasised that besides vitamin D and calcium, supplementation, food rich in micro-nutrients (such as B complex vitamins, plus Ca, Fe, Zn, Iodine, Se, Zn) be offered, so that immunity against any infection is also ensured. Such an addition takes care of what is called ‘hidden hunger’ in poorly nourished people. As cooked food is given in schools in several states, anganwadis and such, the meals offered should have the kind of menu that offers the best combination of vegetable components in the meal. Many nutritionists have suggested that besides dal (or sambar) using pulses, such meals include vegetables like spinach and other green leafy vegetables, beans, peas, carrots, tomato, potato, milk/curd and fruits like bananas, and omega 3 and 6 fatty acids (and an egg) are contained in the meal. Likewise, they have suggested what a balanced non-vegetarian meal could be, which is wholesome, yet affordable.
What is affordable? Madhura Swaminathan of MSSRF writes in The Hindu of July 28, 2020 that as per FAO’s State of Food Security and Nutrition in the World 2020 (SOFI 2020), a nutrient-adequate meal costs PPP $2.12 (or ₹25 per meal or ₹50 for 2 meals per day), and a ‘healthy diet’ about ₹100 per day. For over 370 million poor people in India, this is a big figure! It is clear that besides the valiant efforts of Central and State governments, substantial contributions must come from private foundations (Indian and international), CSR from large industries, and individual donors, so that we may reach this ₹100 per day’s meals. It can be done.
Nutrition from seaweed
Seaweeds are nutritious additions to everyday meals. Mainland India has a coastline of over 7,500 km, and island mass coastline of 5,500 km, and seaweeds, namely algae, are grown and processed for use, including for food. Japan, Korea, China and most Southeastern countries eat them. These are vegetarian, and rich in vitamins, minerals, iodine and omega 3 fatty acids. The Central Salt and Marine Chemicals Research Institute (CSMCRI) at Bhavnagar has published the paper: (Dixit D.C. et al., Assessment of the nutritive, biochemical, antioxidant and antibacterial potential of eight tropical macro algae along Kachchh coast, India as human food supplements, Journal of Aquatic Food Product Technology, 27:1, 61-79, DOI: 10.1080/10498850.2017.1396274 https://doi.org/10.1080/10498850.2017.1396274. It is time that we Indians also begin adding seaweeds in our meals.
(Grateful thanks to Dr. Mahtab Bamji for her continuing advice).