European Journal of Clinical Nutrition (2014) 68, 539–540 © 2014 Macmillan Publishers Limited All rights reserved 0954-3007/14 www.nature.com/ejcn
COMMENTARY
Nurturing public health nutrition education in India S Khandelwal1 and A Kurpad2 European Journal of Clinical Nutrition (2014) 68, 539–540; doi:10.1038/ejcn.2014.42; published online 19 March 2014 Lower middle-income countries, especially India, have a unique double burden of malnutrition in the setting of a rapidly changing economy, with increasing urbanization, nutrition transition and a sedentary lifestyle.1 Improving diet/nutrition and physical activity has a huge restorative potential;2 however, this simple strategy is a daunting challenge for India and the public health nutrition (PHN) community in particular.3 Moreover, India’s scientific and research contributions in this arena—whether in the form of cross-cutting high-quality landmark research studies, publications in peerreviewed indexed journals, world-class training/teaching programs, mentorship and strategies to promote youth leadership—are abysmally low.4 This is also exemplified by the unused (almost 50%) government funding for research in general by the Ministry of Health and Family Welfare (MoHFW), Government of India.5 Education matters! We largely attribute the lack of innovative PHN strategies to curb morbidity and mortality along with poor research outputs to the current nonprogressive academic training. A mapping exercise of all nutrition-related teaching and training initiatives across India revealed o3% institutions offering training in PHN.6 An in-depth curriculum analysis is underway; however, the preliminary findings reveal lack of attention to research, policy or social determinants. The current scenario does not provide
Research • Enhance understanding of diet disease relationships • Examine etiology of community nutrition problems and promote research in this area • Recognize the role of nutrition both in prevention and managment
Figure 1.
enough room or encouragement to nutrition students to develop interest and work in research. This is because the main perceived role of nutritionists in the society is limited to offering therapeutic advice. Even those who wish to engage are unable to fund their positions because of poor grant writing skills, and thus get absorbed in others’ projects with nonprogressive roles. Eventually, those who are not satisfied with this arrangement usually migrate or change their field of work. The case for investing resources in PHN capacity building requires strategic presentation of the current demand–supply scenario. A huge shortfall in public health workforce was highlighted by Narayan et al.7 They estimated that there are only 3587 dieticians per 100 000 Indians. The demand, however, is enormous. In the program/policy domain, nutrition falls under joint ownership of the Ministry of Women and Child Development (WCD), and Ministry of Health and Family Welfare (MoHFW). Potential employers for trained public health nutritionists include (but not limited to) Ministry of WCD, MoHFW, Ministry of Agriculture, Planning Commission, Research Organizations, Government Nutrition programs like Integrated Child Development Scheme (ICDS), Mid-day Meal Program (MDM), women and child health schemes, Nutrition Officers of United Nations (UN) bodies, State level nutrition consultants /officers and so on. The Planning Commission report8 on nutrition challenges in India had proposed having one village-level nutrition counsellor for every 1000 people (India has around 638 000 villages as per 2001 census) and one nutrition supervisor for every 20 village counsellors.
Policy • Include PHN workforce as an integral part of planning, implementing, monitoring and evaluation of goverment nutrition programs/schemes • Create better employment opportunities- include PHN degree in the eligibility crietria
Academics • Reorient the existing infrastructure and HR to deliver PHN education • Improve and invest in strengthening nutrition research environment • Engage in international collaboration, promote exchange programs, faculty development courses etc
Role of stakeholders in enhancing PHN education in India.
1 Public Health Foundation of India, New Delhi, India and 2Nutrition Division, St John’s Medical College, Bangalore, India E-mail: shweta.khandelwal@phfi.org Contributors: SK wrote the first draft, AK provided critical edits and helped to finalize the manuscript.
Commentary
540 The intention of this paper is not merely to lament the Indian nutrition-training scenario, but to highlight that these are modifiable deficiencies.9 We propose that all three—academia, researchers and policy-makers—have a symbiotic role in offering solutions to enhancing PHN education in India (Figure 1). Academically, nutrition is placed under the Home Science discipline in India. The terminology is a deterrent to many who equate this field to the one that imparts skills to be a better home maker. We argue that PHN needs to be identified under the larger rubric of public health sciences and the PHN workers should be recognized as allied health professionals. In addition, the field of Nutrition Science needs an independent recognition (disentangled from Home Science) that can offer specializations like dietetics, food technology and so on. This clarity in nomenclature and scope of nutrition as well as PHN from the top political/ bureaucratic levels, coupled with an increased appreciation for PHN workforce development from the public and private sectors, will lead to remarkable changes in the profile of this discipline. In India, where close to 190 institutions offer nutrition at some academic level, the challenge is not infrastructure but trained faculty and mentors.6 Resources need to be invested in curriculum revisions, rigorous training, teaching research skills and integrating hands-on experiences, along with providing an environment with protected time for scientific reading/writing. We recommend that students need to be sensitized to the PHN challenges in India right from the school level. Interested eligible candidates should have the option of perusing PHN at various levels after completing their intermediary education. For on-the job professionals, short-term training programs and distance learning courses in PHN can be designed. Additional suggestions to promote PHN education include faculty exchange, interdisciplinary and inter-country research, better employment opportunities, more funding opportunities and grants in the area, research fellowships, scholarships for meritorious students, improved utilization of existing government infrastructure and existing centers of excellence.
European Journal of Clinical Nutrition (2014) 539 – 540
To see meaningful and positive changes in the country’s health profile, academic training and human resource generation needs to be complemented with political will, committed funds, equity and multi-sectoral health promotion programs. As academicians and researchers, our plea is to draw high-level attention of all stakeholders to the neglected child ‘PHN education’ and not deprive it of the essential care and nourishment. CONFLICT OF INTEREST The authors declare no conflict of interest.
REFERENCES 1 Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; 3382: 427–451. 2 Lachat C, Otchere S, Roberfroid D, Abdulai A, Seret FMA, Milesevic J et al. Diet and physical activity for the prevention of noncommunicable diseases in low- and middle-income countries: a systematic policy review. PLoS Med 2013; 10: e1001465. 3 Popkin BM. What can public health nutritionists do to curb the epidemic of nutrition-related noncommunicable disease? Nutr Rev 2009; 67: S79–S82. 4 Khandelwal S, Siegel KR, Narayan KMV. Nutrition research in India: underweight, stunted, or wasted?. Global Heart 2013; 8: 131–137. 5 Ministry of Health & Family Welfare GoI, New Delhi Report of the National Commission on Macroeconomics and Health. 2005; Available at http://www.who. int/macrohealth/action/Report%20of%20the%20National%20Commission.pdf (accessed on 17 Jan 2014). 6 Khandelwal S, Dayal R, Jha M, Zodpey S, Reddy KS. Mapping of nutrition teaching and training initiatives in India: the need for public health nutrition. Public Health Nutr 2012; 15: 2020–2025. 7 Narayan, K Kar, S Gupta, N. From 'Paramedics' to 'Allied Health Professionals’: Landscaping the Journey and Way Forward. Public Health Foundation of India: New Delhi, India, 2012. 8 The Planning Commission Addressing India’s nutrition challenges. Report of the Multi-stakeholder Retreat Planning Commission Government of India. 2010; Available at http://planningcommission.nic.in/reports/genrep/multi_nutrition.pdf (accessed 17 Jan 2014). 9 Haddad L. Why India needs a national nutrition strategy. BMJ 2011; 343: d6687.
© 2014 Macmillan Publishers Limited
COMMENTARY
Nurturing public health nutrition education in India S Khandelwal1 and A Kurpad2 European Journal of Clinical Nutrition (2014) 68, 539–540; doi:10.1038/ejcn.2014.42; published online 19 March 2014 Lower middle-income countries, especially India, have a unique double burden of malnutrition in the setting of a rapidly changing economy, with increasing urbanization, nutrition transition and a sedentary lifestyle.1 Improving diet/nutrition and physical activity has a huge restorative potential;2 however, this simple strategy is a daunting challenge for India and the public health nutrition (PHN) community in particular.3 Moreover, India’s scientific and research contributions in this arena—whether in the form of cross-cutting high-quality landmark research studies, publications in peerreviewed indexed journals, world-class training/teaching programs, mentorship and strategies to promote youth leadership—are abysmally low.4 This is also exemplified by the unused (almost 50%) government funding for research in general by the Ministry of Health and Family Welfare (MoHFW), Government of India.5 Education matters! We largely attribute the lack of innovative PHN strategies to curb morbidity and mortality along with poor research outputs to the current nonprogressive academic training. A mapping exercise of all nutrition-related teaching and training initiatives across India revealed o3% institutions offering training in PHN.6 An in-depth curriculum analysis is underway; however, the preliminary findings reveal lack of attention to research, policy or social determinants. The current scenario does not provide
Research • Enhance understanding of diet disease relationships • Examine etiology of community nutrition problems and promote research in this area • Recognize the role of nutrition both in prevention and managment
Figure 1.
enough room or encouragement to nutrition students to develop interest and work in research. This is because the main perceived role of nutritionists in the society is limited to offering therapeutic advice. Even those who wish to engage are unable to fund their positions because of poor grant writing skills, and thus get absorbed in others’ projects with nonprogressive roles. Eventually, those who are not satisfied with this arrangement usually migrate or change their field of work. The case for investing resources in PHN capacity building requires strategic presentation of the current demand–supply scenario. A huge shortfall in public health workforce was highlighted by Narayan et al.7 They estimated that there are only 3587 dieticians per 100 000 Indians. The demand, however, is enormous. In the program/policy domain, nutrition falls under joint ownership of the Ministry of Women and Child Development (WCD), and Ministry of Health and Family Welfare (MoHFW). Potential employers for trained public health nutritionists include (but not limited to) Ministry of WCD, MoHFW, Ministry of Agriculture, Planning Commission, Research Organizations, Government Nutrition programs like Integrated Child Development Scheme (ICDS), Mid-day Meal Program (MDM), women and child health schemes, Nutrition Officers of United Nations (UN) bodies, State level nutrition consultants /officers and so on. The Planning Commission report8 on nutrition challenges in India had proposed having one village-level nutrition counsellor for every 1000 people (India has around 638 000 villages as per 2001 census) and one nutrition supervisor for every 20 village counsellors.
Policy • Include PHN workforce as an integral part of planning, implementing, monitoring and evaluation of goverment nutrition programs/schemes • Create better employment opportunities- include PHN degree in the eligibility crietria
Academics • Reorient the existing infrastructure and HR to deliver PHN education • Improve and invest in strengthening nutrition research environment • Engage in international collaboration, promote exchange programs, faculty development courses etc
Role of stakeholders in enhancing PHN education in India.
1 Public Health Foundation of India, New Delhi, India and 2Nutrition Division, St John’s Medical College, Bangalore, India E-mail: shweta.khandelwal@phfi.org Contributors: SK wrote the first draft, AK provided critical edits and helped to finalize the manuscript.
Commentary
540 The intention of this paper is not merely to lament the Indian nutrition-training scenario, but to highlight that these are modifiable deficiencies.9 We propose that all three—academia, researchers and policy-makers—have a symbiotic role in offering solutions to enhancing PHN education in India (Figure 1). Academically, nutrition is placed under the Home Science discipline in India. The terminology is a deterrent to many who equate this field to the one that imparts skills to be a better home maker. We argue that PHN needs to be identified under the larger rubric of public health sciences and the PHN workers should be recognized as allied health professionals. In addition, the field of Nutrition Science needs an independent recognition (disentangled from Home Science) that can offer specializations like dietetics, food technology and so on. This clarity in nomenclature and scope of nutrition as well as PHN from the top political/ bureaucratic levels, coupled with an increased appreciation for PHN workforce development from the public and private sectors, will lead to remarkable changes in the profile of this discipline. In India, where close to 190 institutions offer nutrition at some academic level, the challenge is not infrastructure but trained faculty and mentors.6 Resources need to be invested in curriculum revisions, rigorous training, teaching research skills and integrating hands-on experiences, along with providing an environment with protected time for scientific reading/writing. We recommend that students need to be sensitized to the PHN challenges in India right from the school level. Interested eligible candidates should have the option of perusing PHN at various levels after completing their intermediary education. For on-the job professionals, short-term training programs and distance learning courses in PHN can be designed. Additional suggestions to promote PHN education include faculty exchange, interdisciplinary and inter-country research, better employment opportunities, more funding opportunities and grants in the area, research fellowships, scholarships for meritorious students, improved utilization of existing government infrastructure and existing centers of excellence.
European Journal of Clinical Nutrition (2014) 539 – 540
To see meaningful and positive changes in the country’s health profile, academic training and human resource generation needs to be complemented with political will, committed funds, equity and multi-sectoral health promotion programs. As academicians and researchers, our plea is to draw high-level attention of all stakeholders to the neglected child ‘PHN education’ and not deprive it of the essential care and nourishment. CONFLICT OF INTEREST The authors declare no conflict of interest.
REFERENCES 1 Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; 3382: 427–451. 2 Lachat C, Otchere S, Roberfroid D, Abdulai A, Seret FMA, Milesevic J et al. Diet and physical activity for the prevention of noncommunicable diseases in low- and middle-income countries: a systematic policy review. PLoS Med 2013; 10: e1001465. 3 Popkin BM. What can public health nutritionists do to curb the epidemic of nutrition-related noncommunicable disease? Nutr Rev 2009; 67: S79–S82. 4 Khandelwal S, Siegel KR, Narayan KMV. Nutrition research in India: underweight, stunted, or wasted?. Global Heart 2013; 8: 131–137. 5 Ministry of Health & Family Welfare GoI, New Delhi Report of the National Commission on Macroeconomics and Health. 2005; Available at http://www.who. int/macrohealth/action/Report%20of%20the%20National%20Commission.pdf (accessed on 17 Jan 2014). 6 Khandelwal S, Dayal R, Jha M, Zodpey S, Reddy KS. Mapping of nutrition teaching and training initiatives in India: the need for public health nutrition. Public Health Nutr 2012; 15: 2020–2025. 7 Narayan, K Kar, S Gupta, N. From 'Paramedics' to 'Allied Health Professionals’: Landscaping the Journey and Way Forward. Public Health Foundation of India: New Delhi, India, 2012. 8 The Planning Commission Addressing India’s nutrition challenges. Report of the Multi-stakeholder Retreat Planning Commission Government of India. 2010; Available at http://planningcommission.nic.in/reports/genrep/multi_nutrition.pdf (accessed 17 Jan 2014). 9 Haddad L. Why India needs a national nutrition strategy. BMJ 2011; 343: d6687.
© 2014 Macmillan Publishers Limited
