National Institute of Nutrition: 100 years of empowering the nation through nutrition

Early studies on nutrient deficiency disorders

While epidemiological studies on beriberi were continued during the early decades of its founding1, special surveys were conducted on beriberi in endemic areas as well as among tribal population in Bihar region. The studies on parboiled and milled rice helped to explain the incidence of beriberi among rice eaters in the east coast of Andhra region where milled rice was consumed largely and no incidence in Madras where parboiled rice was consumed more67. Systematic epidemiological investigations have demonstrated that beriberi has characteristic effects on the chronological pattern of infant mortality89. NRL's focus also turned towards goitrogenic substances, epidemic dropsy, burning feet and bladder stones. Stomatitis associated with the deficiency of B group of vitamins, particularly riboflavin, was described for the first time in India, and a treatment with yeast and skimmed milk was found to be effective21011.

The need to add a clinical dimension and conduct systematic clinical trials was felt, and C. Gopalan was appointed as the clinical assistant to study diarrhoea and nutritional disorders at the Clinical Unit established at Stanley Hospital in Madras (Chennai). This clinical unit was the first to describe a clinical condition called ‘burning feet syndrome’, which was found to be due to vitamin B deficiency, and prescribed its treatment with vitamin B (pantothenic acid)21213.

Nutritive values of Indian foods

One of the important contributions of NIN has been the assessment of nutritive values of commonly consumed Indian foods. This was first taken up in 1935 and was completed in two years. Chemical analysis was performed on more than 200 foods for nutritive values (energy, carbohydrate, protein, fat, vitamin and mineral contents). Besides employing the already established methods for vitamin analyses, newer and improved methods of analyses were employed, especially for the estimation of niacin, carotene and some B vitamins1014. ‘The Nutritive Value of Indian Foods and Planning of Satisfactory Diets’ was published in 1937, in Health Bulletin No. 23, which turned out to be a very popular contribution15. Apart from this, the nutritive values of fruits and vegetables were also determined during 1960s. The project on nutritive values of Indian foods was initiated at four centres (Coonoor, Bombay, Ambala and Mysore) and this work helped to fill gaps in the earlier ‘Health Bulletin’. This work generated new data on nutrient as well as non-nutrient components in a number of foods. The data from all the centres were compiled, and Health Bulletin No. 23, brought out earlier, was updated and revised. The revised edition was published as ICMR Special Report No. 4216 in 1962. This publication was thoroughly revised and rewritten with data obtained after updating some methods of nutrient estimation and was published as ‘Nutritive Value of Indian Foods’ in 1970s17. Analysis of foods for their nutrient composition has been the basis for the periodical revision of this publication.

More recently, the database profiling the nutritive values of Indian foods has been readied in 2017. Adopting the ‘key foods approach’, that contributes up to 75 per cent of the nutrient intakes considered. Using latest techniques and precision tools, the new ‘Indian Food Composition Tables (IFCT) 2017, were brought out. The IFCT 2017 is the compilation of nutritional information on 151 discrete food components for 528 key foods. The IFCT, for the first time in the Indian context, attempted to provide information on almost all regular nutrients in foods alongside a whole range of bioactive substances18.

Formulation of recommended dietary allowances (RDAs)

The first recommendations on Recommended Dietary Allowances (RDA) were made for the Indian context in 1944 based on the recommendations of the Health Committee of the League of Nations (1937)34. Later, the RDAs were modified in the early 1960s, and then in the early 1970s, 1980, 1991 and last in 201019. An expert group constituted by the ICMR in 2008 revised and updated the nutrient requirements as well as dietary allowances for Indians. Data generated in India by NIN earlier became the basis and RDAs were revised compared to the previous versions of 1944, 1958 and 1968. Recommendations for minerals such as calcium, phosphorus, zinc, selenium and iodine have been included as separate chapters.

Dietary guidelines for Indians

A manual with information on the key practicable points for diets and physical activity for Indians to ensure optimal health and freedom from disease was proposed for the first time in 1998. In 2011, after the RDAs were revised and the guidelines were redrafted, the revised version was released20.

Studies on protein-energy malnutrition (PEM)

Studies were conducted on protein-energy malnutrition (PEM) among infants, and some feeding trials were also conducted among children to study the effect of skimmed milk on their nutritional status, which Aykroyd3 claimed as the first-ever studies to give reconstituted skimmed milk powder to children in a developing country and to show that this supplement accelerated growth and improved the general condition. In fact, in later years, skimmed milk powder has been given to a large number of children suffering from PEM and has proved a lifesaver3. The two severe forms of protein-calorie malnutrition investigated during the 1960s by the Institute were kwashiorkor and nutritional marasmus212223_. Detailed studies have been undertaken on the dietary intakes and the biochemical status of children manifesting these different forms of malnutrition with a view to understand the common aetiological background. It was around this time that the dietary intake data from urban-rural multicentric community studies on the diets of preschool children were thoroughly examined for their energy and protein intakes. It turned out to be a surprising revelation that the protein concentration of their diets was nearly adequate contributing to about 10 per cent of their energy; however, the average energy intake was grossly deficient24. This analysis paved way for a new hypothesis that the malnutrition among underprivileged children was due to energy deficiency and not solely due to protein deficiency. The large-scale community studies were initiated to test this hypothesis and this view was soon endorsed even by UN organizations like WHO and UNICEF2.

Studies were carried out to assess whether the poor mental performance of the children is solely attributable to the earlier episode of kwashiorkor or to other causes as well. The observations showed that non-nutritional factors, particularly maternal attitudes, played an equally important role in the mental development of children25.

Providing nutrient requirements for national programmes aimed at vulnerable groups

The NIN through NNMB carried out nutritional assessment surveys on individuals as well as on families, covering different age groups and different socio-economic groups. NNMB reports have been used by nutritionists, epidemiologists, policymakers and more so by the Planning Commission in those days. One of the most significant research findings of the Institute in the 1960s was that the prevalence of severe forms of malnutrition among preschool children was mainly due to energy deficiency and not due to protein deficiency, as was assumed for many decades24. This was one of the bases for the Government of India in the 1970s, to launch a supplementary feeding programme to provide 300 Kcal/day to improve the nutritional status of children in rural areas and in urban slums, which was operated under the Integrated Child Development Scheme (ICDS)4.

Contribution to the National Prophylaxis Programme against nutritional blindness due to vitamin A deficiency (NPPNB due to VAD)

During the 1960s, after some preliminary clinical trials, the effect of oral administration of a large dose of vitamin A on serum vitamin A of 2500 children was studied. Based on this study outcome, the NIN recommended administration of 200,000 IU each to children at six-monthly intervals to avoid immediate toxic manifestations and for providing effective and consistent cover against vitamin A deficiency (VAD)2. This paved the way for a nationwide vitamin A prophylaxis programme with its inclusion in the Fourth Five-year plan in 196926.

Another landmark operational research carried out by the NIN was the feasibility study to link the National Programme for Vitamin A Supplementation to prevent nutritional blindness among young children with a universal immunization programme (UIP) to increase its coverage. In spite of its implementation for over two decades, the coverage for vitamin A supplementation was very poor. The NIN had carried out the above operational research in seven States of India and showed that it was feasible to link Vitamin A Supplementation Programme with the existing high-coverage trends of UIP27. Based on the recommendations of the NIN, it became a national programme and is being implemented throughout India, and the coverage of vitamin A supplementation has increased to over 70-80 per cent in the later years. The prevalence of VAD disorders such as Bitot spots and other ocular signs has significantly declined in later years2.

Supplementation of iron and folic acid to pregnant women

In 1968, a professional body that emanated earlier from NIN, the Nutrition Society of India, set up a study group on nutritional anaemias under the leadership of Gopalan with leading nutritionists and haematologists of those times as members. After carefully examining various studies carried out in India till then, the study group recommended that a programme of iron folate supplementation be taken up for pregnant women and preschool children as a prophylactic measure. The government introduced the National Nutritional Anaemia Prophylaxis Programme aimed at pregnant women and young children in 197028.

Operational research to strengthen nutrition programmes

The Institute carried out operational research studies on ICDS to assess its impact on the nutritional status of children, including process and input evaluation. The study results helped in strengthening of the programme and subsequently, it was expanded in all the villages by universalizing ICDS services. Another study assessed the psychosocial development of children, who were beneficiaries and non-beneficiaries of the ICDS for the estimation of ICDS service impact. The study indicated that the outreach of health, nutrition and child care was better in ICDS compared to that of non-ICDS areas29.

Development of Nutrition Surveillance System (NSS)

In order to promote effective functioning of ICDS and nutritional well-being of the beneficiaries, the NIN developed ‘AAA’ (triple A) approach covering Assessment, Analysis and Action involving the entire ICDS mechanism from the grassroots level to the supervisory level3031. This involved ‘Assessment’ of health and nutritional status on a continuous basis amongst vulnerable population groups, identifying area-specific determinants (Analysis) of nutrition problems and food insecurity and integrating various departments to take appropriate ‘Action’ in the prevention and control of undernutrition.

Nutritional surveys

The NNMB carried out surveys in 10 States and generated a dynamic database on diet and nutritional status of the communities. Many surveys were regularly conducted among rural, tribal and urban populations. The most recent survey was the ‘Diet and nutritional status of urban population in India and prevalence of obesity, hypertension, diabetes and hyperlipidaemia in urban men and women’ released in 201732. Diet and nutritional status of primitive tribes of Andaman and Nicobar Islands was carried out, and the NIN, for the first time, reported that the diet and nutritional status of tribal population was very poor and needed special attention33. Surveys were also conducted among special groups such as Bangladeshi refugees34, tribal populations3536 and people in drought-hit areas37.

Project Grow Smart

The ICMR-NIN designed a study using a micronutrient formulation (iron folic acid, B 12, B2, zinc, vitamin A and vitamin C), which should be blended with food supplement provided to preschool beneficiaries of ICDS. A cluster-randomized, double-blind, placebo-controlled study was conducted in 22 villages of Telangana. The results showed reduction in anaemia within a short span of six months accompanied with higher iron stores in the intervention group as compared to the controls. In addition, there was improvement in the linear growth in the intervention group38.

Balamrutham

The ICMR-NIN in collaboration with State governments has developed micronutrient-fortified (iron, folic acid, B1, B2, B12, niacin, zinc, vitamin A, vitamin C, calcium) take-home ration called Balamrutham for 6-36 month old children, which is being implemented in all districts of Andhra Pradesh and Telangana. Earlier, the integrated State of Andhra Pradesh used to provide Modified Therapeutic Food (MTF) to children (aged 6-35 months) under Supplementary Nutrition Programme of ICDS. The NIN conducted a study comparing the new ready-to-eat (RTE) formulation with the existing MTF and proved that it was a superior food supplement. This led to the introduction of Balamrutham, which reached the mothers and caregivers of over 10 lakh children in Telangana State, making them empowered to take care of their children's nutrition39.

Ultra rice

A study was aimed to determine the impact of ultra rice - micronized ferric pyrophosphate supplied through extruded rice kernels - in a rice-based meal on iron status of children who were beneficiaries of the midday meal (MDM) scheme. The double-blind randomized controlled efficacy trial on delivering an additional 19 mg Fe/day through fortified rice as part of the MDM programme regularly for eight months improved the body iron stores by 8 μg/l and reduced iron deficiency from 33 to 14 per cent in 5-11 yr old schoolchildren, compared to those consuming natural unfortified rice (3 μg/l and 31-37%, respectively). The effects on haemoglobin status, anaemia and iron deficiency anaemia (IDA) were similar in the two groups of children, suggesting that factors other than the additional iron intake had a larger influence. The iron-fortified rice was similar to natural rice in sensory qualities and was well accepted by the children40.

Food toxins

Studies on food toxins explored some major areas such as neurolathyrism, aflatoxicosis, argemone toxicity and epidemic dropsy and erucic acid toxicity in edible oil. Significant contributions have been made by the Institute in identifying the nature of the toxic factors and in providing solutions for prevention and control2. In 1963, a major breakthrough was achieved, when neurotoxic symptoms were induced in baby chicks by the administration of aqueous alcoholic extracts of the khesari dal (Lathyrus sativus) seeds. The toxic factor was identified to be an unusual amino acid, called β-(N)-oxaly1 amino alanine4142. Later, steeping or parboiling of the pulse at home or on commercial scale has been shown to lessen the toxicity42.

Investigations on epidemic dropsy

In 1998, epidemic dropsy was reported from several States such as West Bengal, Bihar, Orissa (now Odisha), Madhya Pradesh, Haryana, Assam, Jammu and Kashmir, Uttar Pradesh, Gujarat, Delhi and Maharashtra, mainly due to consumption of food cooked in argemone oil mixed with mustard oil. The NIN carried out a study on epidemic dropsy prevalent in the areas of State of Madhya Pradesh and recommended to the government to stop the unauthorised use of adulterated oil. Selective cultivation of yellow mustard, strict enforcement of regulation and exemplary punishment to unscrupulous traders were followed as preventive measures2.

Knowledge, attitude, belief and practice (KABP) study on food safety

The FDTRC (then a separate centre within NIN) spearheaded the knowledge, attitude, belief and practice study on food safety in 2005-06 which was conducted among households and other stakeholders such as doctors, regulators and teachers in 28 States of the country. The findings of the study were used by the Ministry of Health & Family Welfare for food safety education using electronic media43.

Pre-clinical toxicology

The Preclinical Toxicology Centre (PCT) was established in 1999 in NIN. Since its inception, the Centre has screened recombinant products (anti-rabies vaccine, interferon, tetravalent vaccine and HPV oral vaccine), indigenously developed peptides, and involved in traditional preparations such as Bhasmas (herbomineral preparations, Ayurvedic formulations) and food additives. About 80 per cent of the products screened by the PCT are in clinical trials and a few are in clinical use.

Generated data on the prevalence of non-communicable diseases (NCDs)

Most recently, in 2017, the NIN has generated data on the prevalence of overweight/obesity and non-communicable diseases (NCDs) in urban and rural areas from 16 States of India. The urban survey alone covered as many as 1,71,928 individuals from over 52,500 households of 1097 wards of 16 States32.

Fenugreek seeds in the management of diabetes

It was found out that fenugreek seeds could improve the glucose tolerance and ameliorate other symptoms of diabetes mellitus (type 2). It was reported that the mechanism of action of fenugreek seeds on improving glucose tolerance in diabetes was due to improvement in glucose utilization at the cellular level44.

Research on edible oils

In the 1980s when there was a concern about the inadequate production of edible oil in India, the Government of India's policy of looking at promoting the use of unconventional edible oils got attention. Systematic studies on the nutritional quality and safety evaluations of unconventional edible oils such as rice bran oil, mango kernel oil, palm oil, neem oil, tumba oil and crude palm oil were carried out at the NIN45464748495051.

Recommended use of multiple oils

The relative role of n-3 and n-6 polyunsaturated fatty acids (PUFAs) in regulating the plasma profile was studied, and the desirable ratio of these fatty acids in Indian diets was worked out52. Based on these studies, it was advocated to blend or use a combination of oils to reap the benefits of n-3 and n-6 fatty acid form of different oils. Different socio-economic groups consuming different amounts and varieties of fat showed that n-6 PUFA nutritional status was good, while the status of n-3 PUFA needed improvement. Studies showed that long-term use of cooking oil (blend of sunflower oil and canola oil) containing 20-40 per cent n-6 PUFA and four per cent alpha-linolenic acid (with n-6/n-3 ratio = 6-9) in cereal pulse-based total diets improved n-3 PUFA status. Based on these studies, the NIN recommended the use of more than one oil as diverse sources of oils confer the additional advantage of providing a variety of minor components (present in non-glyceride fraction of oils)5354.

Health effects of trans fats

The health effects of dietary trans fatty acids present in the partially hydrogenated vegetable oil (vanaspati) were investigated5556. Studies showed that compared to saturated fats, trans fats present in vansaspati decreased the insulin sensitivity to a greater extent53. Considering the detrimental effects of trans fatty acids, the Food Safety and Standards Authority of India (FSSAI) fixed the norms for trans fatty acid content of vanaspati, limiting to 10 per cent, and proposes to bring it down to five per cent and to two per cent or lesser than that in the next couple of years57.

Studies on anticancer properties of Indian spices

Studies on nutrition and cancer elucidated the role of micronutrients in susceptibility to/prevention of cancer of the gastrointestinal tract. Studies on micronutrients/trace element status of cancer patients and age- and economic group-matched normal controls showed that cancer patients had lower vitamin A, riboflavin, folate and selenium5859. Studies on Indian spices, especially on turmeric and ginger, had demonstrated their anticancer properties6061. Antimutagenic properties of some foods such as turmeric, ginger and garlic were also explored6263.

Training programmes/courses

Two systematic training programmes for medical college faculty and public health personnel were initiated to impart training in the current concepts of nutritional science and their application for promoting public health. One was the 12 wk Post Graduate Certificate Course (started in 1963) and the other was the nine-month MSc (Applied Nutrition) Postgraduate Programme (initiated in 1968). The World Health Organization (WHO), UNICEF and Food and Agriculture Organization (FAO) also sponsored many candidates to take part in these training courses annually. The nine-month M. Sc. (Applied Nutrition) Postgraduate Programme was discontinued in 2004 and, in its place, a two-year master's programme (affiliated to Dr. NTR University of Health Sciences, Vijayawada) was introduced in 2009 and later the affiliation was shifted to Dr. Kaloji Narayana Rao University of Health Sciences, Warangal, in the State of Telangana. In 2018, with the support from the Ministry of Youth Affairs and Sports, an MSc Programme in Sports Nutrition was initiated.

Information Communication Technologies (ICTs) for nutrition outreach

The NIN initiated efforts to use ICTs for public dissemination of nutrition messages. A series of mobile applications on Dietary Guidelines for Indians, RDAs, were developed and put on public domain for free downloads and use. In 2018, Nutrify India Now (NIN App), a mobile App developed by the NIN was launched, which helps users assess their nutrient intake from food and also keep track of energy balance. The usability is extended to majority of the Indian States as all food names are provided in 17 Indian languages.

Studies on food label information use in India

Studies conducted at NIN are among the first in India to assess the consumer use of food labels. The studies pointed that literate consumers were more likely to read the label information for food choice7172. A nutritional education intervention study among adolescents evaluated the impact of ‘Read-B4-U-Eat’ - a label information education module - on the label-related knowledge and usage of such information for food choices. Theories of social cognition and shared learning were used to develop the module's five components - booklet for self-learning; interactive lecture sessions for guided learning; posters for shared learning; an animation film for edutainment and printed notes for teachers to reiterate. The kit was efficacious and effective in inculcating label-reading skills among adolescents73.

Scientific outreach for the visually challenged

The NIN brought out three of its popular publications - ‘Dietary Guidelines for Indians’, ‘Diet and Diabetes’ and Diet and Heart Diseases’ - in Braille format for the benefit of the visually challenged. This is part of ICMR's inclusive approach for science and technology dissemination and promoting public health. These books have been distributed to visually challenged individuals and institutions catering to such students across the country free of cost.

Double-fortified salt (DFS)

NIN's research efforts focused on developing a technology for double fortification of salt with both iodine and iron to combat both IDD and iron deficiency anaemia (IDA)74 led to the development of a successful formula after exploring several stabilizers to ensure the stability of iodine on storage, no discolouration and bioavailability of both micronutrients when taken with food. Community trials were conducted in late 1990s to test the acceptability of double-fortified salt (DFS). To know its stability, safety and impact in the reduction of IDA and IDD, a landmark randomized clinical trial was carried out in the Rampachodavaram tribal areas of Andhra Pradesh, where the twin problems were highly prevalent. The study showed a significant reduction in the prevalence of IDD and a moderate impact on anaemia7576.

Transfer of DFS technology and contribution to regulation on fortification

The technologies for DFS and fortification of wheat flour with iron and other nutrients such as vitamin A and folic acid have been transferred to the industry. The NIN also contributed to the preparation of the regulatory specifications for FSSAI for DFS. In 2011, the government issued instructions for the introduction of DFS in ICDS, MDM and PDS and to conduct Information, Education and Communication campaign on the promotion of DFS77.

Dried blood spot (DBS) facility for vitamin A estimation

A dried blood spot (DBS) method for the estimation of serum retinol, a marker of vitamin A status, was established and validated at the NIN with technical support from Craft Technologies, USA. Further, in vitro bioavailability screening methods of iron, zinc and carotenoids were established4. These methods were extensively used for testing the efficacy of fortified food and beverages as part of the public–private partnership programmes. A national facility for DBS estimation of micronutrients was established in the NIN in 20064.

ELISA diagnostic kit for measuring serum ferritin

This kit uses the ELISA method to screen serum ferritin and is accurate, convenient and cost-effective compared to other available technologies. This test helps diagnose, with certainty, the extent of iron deficiency in the body. This kit can also be used to assess bioavailable iron in foods fortified with iron4.

Maternal, child and adolescent health

Nutrition, during the first 1000 days, is an important area for intervention for all developing countries and countries in transition with high burden of malnutrition. The NIN will focus not only on the 1000 days, but also on nutrition before pregnancy to break the intergenerational cycle of malnutrition. To this end, the research will focus on nutrition during pregnancy, lactation and infant and young child feeding practices for reducing low birth weight and stunting as a short-term strategy and on adolescent girl nutrition as a long-term strategy to improve the peri-conceptional nutritional status. This approach will also help explore ways and means to minimize the early onset of coronary heart disease and/or type 2 diabetes in young adults related to early-life nutritional deprivation.

Geriatric nutrition

While India is home to a fifth of the world's young and productive population, the burgeoning nutritional problems of the growing geriatric population cannot be left behind. The Institute would endeavour to take up mapping of micronutrient deficiencies mainly looking at the influence of dietary intakes on dementia, Alzheimer's disease, etc.

Outreach through ICTs and e-learning modules

Use of ICT tools and mHealth (mobile health) technologies such as mobile apps for nutrition, food safety and health message dissemination are key priorities. The NIN is also developing e-learning modules to empower the people across the economic, social and regional spectra of the country. The NIN would serve as a nodal knowledge and dissemination hub for this initiative supported by the Ministry of Women and Child Development, Government of India.

Easy-to-use indices

Studies are also on to develop easy-to-use indices to assess diet diversity, food safety and healthy eating and living of adolescents at household level that can be used for rapid assessment, cutting short the elaborate studies otherwise required.

Dietary reference intakes (DRIs)

The Institute is initiating efforts to generate data on adequate dietary intakes of apparently healthy Indian population from various regions of the country and also generate data on their anthropometry, body composition and micronutrient status. This along with RDAs and tolerable upper limits of nutrients would help arrive at the dietary reference intakes for Indians.

India Nutrition Report (INR)

Several large datasets, on a wide range of health and nutrition indicators across India, collected through surveys periodically by agencies such as National Family Health Survey (NFHS), National Sample Survey Organization (NSSO) and NNMB are available. There is a need for triangulation detailed analysis of these datasets using advanced statistical methods. The INR would be an attempt by the NIN to comprehensively analyze all the information together for understanding the complex relationships between various factors affecting the health and nutrition, with special focus on childhood malnutrition and NCDs, using multilevel modelling, regressions, structured equation models and decision tree techniques to identify the determinants. This will take into consideration the epidemiological transition of different States based on disease burden and also the performance of states on various health system indicators.

The philosophy and the guiding principles of the NIN over a century of its existence have been the understanding of major nutritional problems that confront the country from time to time and finding practical solutions to counter these. The NIN has always been a harbinger of nutrition research in the country and has been a trailblazer in ways more than one. During its centenary year, the NIN rededicates itself to contributing to the well-being of people by empowering the nation through nutrition.