Non-communicable diseases (NCD), including cardiovascular
diseases (CVDs), diabetes, cancers and chronic respiratory diseases, accounted
for at least 50% of all deaths worldwide in 2005 and projected to increase to
more than 60% by 2015 with major brunt being borne by low and developing
countries. In terms of attributable deaths, the leading NCD risk factor
globally are raised blood pressure (to which 13% of global deaths are
attributed), followed by tobacco use (9%), high blood glucose (6%), physical
inactivity (6%), and overweight and obesity (5%). In addition to causing premature deaths,
these diseases cause complications and disabilities, limit productivity,
decreases quality of life, require costly treatments with implicit social
burden and adverse health financing outcome for individual, family and country.
Background
Fruits
and vegetables (F AND V) provide a diversified, flavored, colorful, tasty, low
caloric, and protective, micro-nutrient rich diet. Overall it is estimated that
low F AND V intake is attributable to approximately 2.7 million (4.9%) annual
deaths and 26.7 million (1.8%) DALYs and causes about 31% of ischaemic heart
diseases (IHD), 11% of stroke and 19% of gastro-intestinal cancers and still
significantly associated (protective) with lung/pharyngeal/laryngeal/oral
cancer, type-2 diabetes mellitus, bone-health, vision/cataract and
micronutrient deficiency state. Low F AND V intake is considered as the sixth
main risk factor for mortality in the world.
The Lyon Diet Heart Study demonstrated that a 'Mediterranean
diet' (which is high in F AND V) substantially reduced the risk of incidence
and mortality from myocardial infarction (MI) when compared with low fat diet
alone. The results of Indian Experiment of Infarct Survival (IEIS) showed that
consumption of low-fat diet enriched with F AND V, compared with a standard
low-fat diet, was associated with about 40% reduction in cardiac events and 45%
reduction in mortality after one-year. A study carried out in south India too
observed higher F AND V intake explained 48% of protective effect against CVD
risk factors in the studied population. While results from the Dietary
Approaches to Stop Hypertension (DASH) trial suggested that changes in dietary
fats do not necessarily accompany automatic increase in F AND V intake.
Global Consumption of Fruits and Vegetables
Globally,
majority of people consistently are consuming less than the daily recommended F
AND V requirement. Even in developed nations e.g., Australia, Canada, Europe,
UK and USA, researchers have concluded that there is large gap between actual
and recommended consumption of both F AND V despite decades of concern and
publicity while resultant outcomes were short-lived. In a study from 52 low and
middle-income countries 77.6% of men and 78.4% of women consumed less than the
minimum recommended servings of F AND V. Same study reported 74% low F AND V
consumption amongst adults in India.
Let's analyze the situation in USA for better appreciating
the challenges and need for early action. In 1991, about 8% of individuals
reported being aware that F AND V intake should be at least five servings a day
and this proportion had increased to 40% in 2004.But this heightened awareness
did not translate into behavior change as trends in consumption showed that
intake of fruit had not changed and intake of vegetables had decreased slightly
during the same period. A review from the National Health and Nutrition
Examination Study (NHANES) found that only 0.9% of adolescents, 2.2% of adult
men, and 3.5% of adult women met their dietary guidelines for both F AND V.
Nearly third of US children are overweight/obese. Further, it is not surprising
that 8 states that have the lowest F AND V consumption are also among top 10
highest obesity ranking states. Similarly, Behavioral Risk Factor Surveillance
System (BRFSS), found that only 32.5% of adults ate fruit two or more times
daily and only 26.3% ate vegetables three or more times a day.
Consumption of Fruits and Vegetables in India
Traditionally,
Indian life style has a predilection for fresh F AND V or those processed at
home. On the contrary, surveys indicate a consistently low consumption of F AND
V. Avg. household consumption of F AND V indicate 149 (fruits: 20) to 152
(fruits: 27) during this decade though far below the recommended intake but
slightly better from the previous survey (120-140 g/capita/day). Annual
consumption (kg/person/annum) of fruits was 9.6 (rural), 15.6 (urban) and 11.8
(India) while it was 74.3 (rural), 79.1 (urban), 76.1 (India) for vegetables.
According to latest National Sample Survey Office (NSSO) survey revealed that
out of 1000 household in India, vegetable consumption was reported by 983
(rural) and 932 (urban) whereas fruits by 608 (rural) and 777 (urban)
residents. Other recent studies on avg. consumption of F AND V amongst urban
residents of Chennai and Jaipur reported as 265 gm/day and less than 3 servings
by 72.6% respondents respectively.
Non-communicable disease (NCD) risk factor survey carried
out in seven states using WHO 'STEP' approach under integrated disease
surveillance project (IDSP) showed that people consumed vegetables four to
seven days and fruits two to three days in a 'week'. Fruit consumption was
higher in urban areas but no difference was noticed in vegetable consumption
across rural-urban divide. The proportion of respondents eating less than five
servings of F AND V ranged from 76% (Maharashtra) to 99% in Tamil Nadu. Similar
low consumption has been highlighted in NFHS-3 survey that rises significantly
with wealth status. 'Weekly' consumption of fruit increases from 16% in the
lowest to 72% in the highest wealth quintile. At one end of spectrum,
micronutrient deficiency state is wide-spread e.g. more than 70% children, 55%
adult women and 24% men having some form of anemia. While at other end, this
survey on the basis of body mass index (BMI) also highlighted that 13% of women
and 9% of men are overweight/obese in country with at least 20% of women being
overweight/obese in Punjab, Delhi, Goa, Kerala and Tamil Nadu.
Recommended Intake of Fruits and Vegetables
The
general recommendation for intake of F AND V is at least 400 grams per person
per day (five serving of 80 g each day) or about 146 kg per person per year.
Similarly, national nutrition guidelines recommends avg. daily consumption of
300 g for vegetables (portion size = 100 gm × no. of portions = 3) and 100 g of
fruits (portion size = 100 gm × no. of portions = 1). The vegetables include
(green leafy vegetables = 50 gm, other vegetables = 200 gm, roots and tubers =
50 gm). A glass of fruit juice (excluding sweetened beverages) counts towards a
portion of fruit each day although whole fruit is encouraged for its fiber
content in-conjunction with active life-style.
Production of Fruits and Vegetables in India
India
is second largest producer of F AND V in the world, accounting roughly 10% and
15% respectively, of total global production. Of the available 194 million
hectares of land for agriculture (total cropped area) which happens to be the
principal source of livelihood for 58% of population, the area under F AND V is
about 8%. The production of F AND V crops was 72.3 and 133.5 million tons in
the year 2010 with per capita availability of 172 and 318 gm/day respectively.
The diverse agro-climatic zone in the country makes it possible to grow almost
all varieties of F AND V (be it tropical, semi-temperate, or temperate type)
which together constitute about 92.3% of total horticultural production (F AND
V, roots, tubers, flowers, aromatic, medicinal plants, spices and plantation
crops) in the country. F AND V are typically grown in field conditions; the
concept is opposed to cultivation in green houses as practiced in developed
countries for high yields.
India leads the world in the production of mango (40%),
banana, papaya, sapota (30%) and lime and in productivity of grapes per unit
land area. In case of vegetables, potato, tomato, onion, cabbage and
cauliflower account for around 60% of the total vegetable production in the
country. Andhra Pradesh is the largest producer of fruits in India with an
estimated share of 16.9% followed by Maharashtra (15.6%), Tamil Nadu (11.1%),
Gujarat (8.8%) and Karnataka (8.7%). Other important fruit producing states are
Jammu and Kashmir, Uttarakhand, Uttar Pradesh, Bihar, Jharkhand, West Bengal,
Kerala and Madhya Pradesh.
Challenges: Production to Consumption
There
occurs relative shortfall of F AND V in meeting nutritional required need of
population not at production but due to mismanagement at subsequent levels.
Because of the inherent perishable nature of the produce/short shelf life of
these crops, as much as 30-35% of F AND V perishes during harvest, storage,
grading, transport, packaging and distribution. Wastage of F AND V due to poor
post-harvest management and lack of cold chain facilities have been estimated
to cost up to Rs 13,600 crores and 14,100 crores annually. Further on the flip
side only 2% of these crops are processed into value-added products such as
juices and concentrates, pulp, canned and dehydrated products, jams and
jellies, pickles and chutneys while the processing ranges from 80% to 30% in
USA, China, South Africa, Brazil, Chile, Philippines, Malaysia, Thailand etc.
It is not surprising to note that wastage is a universal phenomenon. According
to FAO, per capita food wasted by consumers in Europe and North-America was
95-115 kg/year, while this figure in Africa and Asia was only 6-11 kg/year. In
UK, by cost, 35% of the wasted food comprised of F AND V and by weight, it
constituted 40%. Australian consumers threw away $5.3 billion worth of food in
2004, over half of which was fresh food, such as F AND V.
F AND V is a labor and risk
intensive sector compounded by other weaknesses like farmer ignorance, food
security concern, lack of credit with farmers to diversify and allocate large
areas of land for horticulture production, non-availability of good quality
seeds, impoverished yield, pest/birds/animal menace, poor infrastructure,
in-sufficient cold storage space, unreliable transportation, high electricity
tariff, taxation and fees structure, massive un-organized sector,
under-utilized public private partnership instruments, in-adequate use of
technology, poor compliance to safety standards, inadequate quality control,
lack of Research and Development, labeling and certification challenges as
display of nutritional facts label is mandatory under the law, costly packaging
and difficulty in finding buyers. These factors could be summed into
production, supply chain and market promotion, development and access issues.
At consumer level income, price,
access, individual taste preferences, consumer awareness, quality
consciousness, decision making power, working status of women, beliefs,
cultural values, perception, attitude, traditions, as well as geographical,
environmental, and other social factors (preparation, storage and handling of
food) all interact in a complex manner to shape dietary consumption patterns of
individual and household. The other possibility could be that till such time
the physiological need to satisfy hunger is met, households have little choice
but to focus on cheap sources of energy such as grain and starchy staples. This
is especially true for people in low and middle income countries. A survey of
infant feeding among Asian families residing in England showed that at five
months of age, 75% of Pakistani (and White mothers), 63% of Indian mothers and
61% of Bangladeshi mothers were giving fruit juices as source of non milk
drink. Another UK based study demonstrated that a healthy shopping basket cost
around 38% more than unhealthy one. Once household have satisfied their basic
energy needs, they starts diversifying their diets by including animal source
food, dairy products and F AND V, thereby increasing the role of consumer
preferences in shaping food consumption pattern and choices.
NSSO report based on 100,794 households revealed that
average monthly per capita consumer expenditure (MPCE) for Indian citizen stood
at Rs. 1984 (total food: Rs. 881 and non-food items: Rs. 1104) in urban and Rs.
1054 (total food: Rs. 600 and non-food items: Rs. 453) in rural India with
share of F and V as Rs 175.2 (urban) and Rs 112.9 (rural) area. Thus F AND V
constituted 10.7% (rural) and 8.8% (urban) MPCE (2009-10). In comparison from
previous NSSO survey it emerges that share of F and V in consumer expenditure
(and also consumption) has not improved i.e., 10.7% (1987-88) to 15.7%
(2007-08) in rural and from 13.9% to 16.6% in urban India. The report also
observed that 39% urban and 7.0% rural house-holds possessed a refrigerator;
in-contrast to 99% in USA. Depending on the level of motivation this is another
challenge for F AND V consumption. On other hand, widely held belief that the
man of the house gets lion's share of the food basket at the expense of the
woman was not found to be true, at least in the states surveyed by the NNMB. No
gender discrimination was observed in any of the age groups, with respect to
intra family food distribution however poor child feeding practice was
extensive. Probably efforts, motivation and/or patience were missing in the
community.
In the backdrop of accelerated urbanization, environment
improvement, opening of food malls, easy availability of packaged foods/drinks,
dedicated 24 × 7 food television channels, food magazines, rising disposable
income, irregular food habits and life style changes a reflection for countries
in economic transition is aiding the path of nutritional and epidemiological
transition. Occasional F AND V contamination reports due to insecticide
excess/poor sanitation has often lead people to develop cautious attitude in
consuming these natural foods. Last but not the least, market forces are
capturing young minds and tongue with junk food using multi-media strategy as a
result F AND V is getting marginalized and ousted from mainstream menu.
Looking at a Brighter Prospect
Agricultural
production, food systems and population health are intimately linked. There are
three main sources of growth in crop production- expanding the land area,
increasing the frequency at which it is cropped and boosting yields. The
budgetary and policy interventions for production enhancement needs to be
supplemented by other measures like strengthening and developing system for
increased absorption, wastage prevention, processing of F AND V into other
value added products under the challenge of technology advancement vs.
environmental protection. Government of India through National Horticulture
Mission (NHM) has taken up many new initiatives recently in this context with
articulation of vision statement, strategy and drafting of future road map
which includes but not limited to integration of multiple schemes, area
expansion, technical advice to farmers/cooperative, setting up nurseries and
tissue culture units for production and distribution of quality planting
material, precision/organic farming, rejuvenation of old orchards, creation of
water sources, minimum support price, financial assistance, air freight
subsidy, market infrastructure development, handling system, cold storage, long
distance mobile units, pack houses, establishment of ripening and vapor heat
treatment facilities, integrated cargo handling, development of mega food
parks, accreditation of quality testing labs, 24 × 7 helpline, technology
promotion and dissemination, development of data bases and live market
information, etc.
The results will be evident over-time but a matter of
concern is the slow and tardy pace of implementation of schemes and poor
monitoring. The gaps are compounded by overall pitfalls and threats like issue
of poor roads, transportation, inadequate electricity, log-jams, climate
variability, inflation, corruption, political (in) stability and governance
issue. India has to evolve from viewing food security at the aggregate level to
ensuring nutrition-security at the individual level. The scale of revamping
required for boosting F AND V in Indian market requires infrastructure,
linkages and management more than that brought into vaccine sector. Current
policy direction is skewed towards overcoming under-nutrition as has been the
requirement but now is the time that it is stirred and shaken for future action
also i.e., prevention of chronic NCDs.
International agencies are coordinating and engaging
national authorities for developing plan for production, processing, promotion
and management. With maturing of Indian media (print/electronic), it is
actively engaging audiences through multiple platforms to initiate and maintain
diet rich in F AND V. Majority of hospitals in country serve at least one-fruit
on daily basis in their admitted patient's menu barring medical exclusion.
There is simultaneous rising trend of ready to drink and convenient (be it
package or natural) fruit juice consumption in urban areas. Dietary advice and
counseling is in-built into primary health care approach while role of
community and home based gardening to increase F AND V availability at house
hold level cannot be undermined but emphasis and efforts on stimulating F AND V
consumption has been so to say non-existent. An innovative integrated child
development scheme (ICDS) successfully delivered on many fronts but failed to
realize its primary outcome in context of nutrition. It can be argued that
there are no-takers for generic advice but persistence pays-off in long run
with specific quantifiable messages.
Ministry of Health and Family Welfare (MOHFW)
operationalized National Programme for Prevention and Control of Diabetes,
Cardiovascular Disease and Strokes (NPCDCS) on pilot basis in 2008 and there
have been some development but till date continues to be in 'infancy' stage.
Probably, its failure and/or learning led to conceptualization and launch in an
integrated manner along with cancer control in 100 districts during 2010. We
will have to wait and watch to see how it evolves over-time in performance
delivery since one of the limitations is non-availability of specialist in
difficult areas. Annual health survey (AHS) was conceived during 2005 to
monitor RCH indicator at district level and its scope has been enhanced to
assess lifestyle trend and risk factors related to NCD also in 9 states
starting from the year 2012 by Registrar General of India (RGI). Parliament
repealed all previous seven existing law related to food items (including
Prevention of Food Adulteration (PFA) act, 1954; Fruit product order, 1955 etc.)
and enacted uniform, integrated and comprehensive Food Safety and Standard
(FSS) Act, 2006 that came into effect from 2011. Under it, Food Safety and
Standards Authority of India (FSSAI) a statutory institution operates under
aegis of MOHFW. It is currently framing guidelines on quality and safety of
foods to be made available or restricted within and around schools.
Interestingly, MOHFW building complex has an outlet that offers fresh fruits
and juices to visitors on nominal payment basis.
A dedicated website healthy-india.org has been created for
information dissemination. Advocacy, consumer awareness and out-reach
activities were started on life style modification, tobacco control, healthy
diet, promotion of F AND V however it needs to be up-scaled to enhance
visibility. It is a known fact that substantial amount of funds allocated by
government of India (GoI) to states as also observed in recent NRHM scam and
more so on information education and communication (IEC) component gets
siphoned off at multiple levels thus compromising the quality, quantity, scale
and reach of health-messages to community at large. Stringent institutional
checks and social audits are required to be established and/or strengthened in
this direction.
ICMR has fostered international and local collaboration for
establishing institutional and community surveillance for NCDs in country.
Various bodies like NIN, NNMB, NFI and research organization are overseeing and
monitoring consumption pattern and trend. Large number of health/nutritional
teaching and training institutions in country including AYUSH (which now also
include Sowa Rigpa) are imparting on-line, certificate, diploma courses,
graduate, higher degrees and in-service training. Thus the scope and potential
for promoting F AND V are plenty within available resources however these needs
to be harnessed and tapped on priority basis.
With ever raging continuing debate of academics vs. physical
activity, school health program is underway with focus on health promotion but
how much is actually being delivered on instilling positive food habits
including F AND V promotion is a matter of evaluation. It would be interesting
to undertake a survey to assess knowledge, attitude, consumption pattern,
determinants and attempts (if any) undertaken for promotion of F AND V by our
key human resource- Anganwadi workers, ASHA, health workers, teachers, medical
officers and teaching faculties. Such exercise if undertaken at regular
intervals would definitely lead to driving the issue across the minds of
pivotal stakeholders resulting in cascade effect.
Conclusion
India
can learn from experiences of various communication campaign initiated across
globe for promotion of F AND V such as "5-a day"; just add F AND V in
your diet; plant F AND V in your lunch box; love fruit-hate waste and suitably
adapt and incorporate in our setting. Innovative strategies for communication
at consumer level could include mobile/internet/video-games, toys/cartoon
character or play-way based activities; observing national/state/district F AND
V day; offering hygienic fruits in meetings/conference/seminars and
schools/colleges. In the present circumstances, increasing F AND V consumption
and preventing wastage may appear difficult, daunting but also feasible task.
With the changing epidemiological profile and legacy of malnutrition, promotion
of F AND V consumption as a public health issue needs urgent attention. The NCD
epidemic is inevitable and approaching fast therefore it is prudent to target
sustained intervention to make an impact, early the better. In this context,
medical colleges through department of Community Medicine can initiate and
sustain NCD risk factor surveillance including F AND V consumption pattern
amongst students, employees and population covered through outreach centres
depending upon level of available resources. To conclude, all said and done
still the greatest challenge across the globe is to translate knowledge into
sustained behavioral action, with no single solution in sight for enhancing
consumption. On a positive note, let's make a humble beginning by introspecting
our consumption pattern and ensuring every opportunity for communicating and
eating seasonal F AND V using daily checklist!
Source: Indian Journal of
Community Medicine 2013
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