Context

In the context of recently releasedthe Global Nutrition Report 2018, we shall analyse the status of nutrition in India in this article.

Fast Facts:

• Indiasuffers from twin-problem of under-nutrition and obesity. Malnutrition is more common in India than in sub-Saharan African countries where per capita income is much lower than that of
• Andhra Pradesh, Andaman and Nicobar, Puducherry and Sikkim have more than 30% of their populations falling under the “obese” category.
• More than 10 per cent population in Bihar, Madhya Pradesh, Meghalaya, Tripura and West Bengal is obese; doubling since the last National Family Health Survey of 2005-06.
• North-South variations– District-level data highlighted in the report shows high and very high levels of stunting mainly in central and northern India (more than 30% and 40%, respectively), but less than 20% in almost the entire south.
• Intra-State Variations: For instance, despite stunting levels in Odisha being 34.1% (also known as ‘high prevalence’) certain districts such as Cuttack (15.3%) and Puri (16.1%) are among the top 10 ‘low stunting level’ districts in the country.
• Urban-Rural Variations: There is pervasive under-nutrition especially in rural areas with PEM (protein and energy malnutrition). Overweight prevalence was higher in urban areas than rural areas.
• Gender Variations: Women have a higher burden than men when it comes to certain forms of malnutrition: one third of all women of reproductive age have anaemia and women have a higher prevalence of obesity than men.
• Age Group Variations: Most children under age three are anemic (79.2%). The prevalence is slightly higher in rural areas and among non-educated mothers.
• Class Variations: People who are poor are more likely to be affected by different forms of malnutrition. Whereas, people with enhanced purchasing power are victims of over-nutrition in India owing to unhealthy food habits and lifestyle.

Global Nutrition Report 2018

• The Global Nutrition Report acts as a report card on the world’s nutrition—globally, regionally, and country by country—and on efforts to improve it.
• It assesses progress in meeting Global Nutrition Targets established by the World Health Assembly.
• The World Health Organization is a Global Nutrition Report Partner.

Global Nutrition Report 2018 and India

• The Global Nutrition Report, which looked at 140 countries including India, found ‘significant burdens’ of three important forms of malnutrition used as an indicator of broader trends.
• District-level data show high and very high levels of stunting mainly in central and northern India (more than 30% and 40%, respectively), but less than 20% in almost the entire south.
• Food and freedom go together, and the availability of one strongly influences access to the other
• Social institutions can work to improve nutrition and children’s welfare in free societies
• The absence of hunger enables people to develop their capabilities.
• The quality of nutrition in packaged foods available to children. Going by the report, only 21% of these foods in India were rated as being healthy. The fact that the global average of processed foods scored only 31% and a peak of 37% in New Zealand indicates that whole foods and cooked meals emerge superior.
• India should invest more of its economic prosperity in its welfare system, without binding itself in restrictive budgetary formulations.

Reasons of malnutrition in India

• Availability of food versus nutrition insecurity
  • India is the world’s third largest producer of food but Indianagriculture is basically cereals-driven.
  • Agriculture policies impact food output, availability and prices. We have the resources to fight malnutrition, but there is little coordinated effort among various departments.
  • PDS issue- Government policies support subsidized delivery of calories but not proteins.
  • Despite growing production, India’s protein use has gradually declined in the last 20 years.
• No convergence among government schemes-
  • There are multiple about half a dozen schemes to address malnutrition. These include Public Distribution System, Midday Meal Scheme, Integrated Child Development Programme and so on.
  • These are implemented by as many ministries as there are schemes but there is little coordination.
  • Also, programme implementation is tardy and not uniform across the country.
• Poverty and underemployment/unemployment-
  • People lack access to ‘nutritious food’. A major share of Indian population earn less than minimum basic wage to earn a good life.
  • Also, economic growth is not turning into increased jobs which eventually restricts access to more nutritious intake like fruits, vegetables, milk, etc.

• Among Women:
  • Education and Reproductive rights–
  • Women are discriminated from womb to tomb.
  • In India, majority of women are underweight (especially pregnant women), anaemic, lack reproductive rights in the form of having number of children and spacing between child birth. It not only adversely affects woman’s health (calcium and iron deficiency) but also leads to low weight babies birth.
  • Lack of awareness about the benefits of breastfeeding to newborn.
  • Education levels being effectively low results in poor decision making with regards to health, reproduction, child care and nourishment.
  • Claiming of maternity benefits is an arduous task as most of the women work in informal sector.
• Among Children:
  • Early childhood careinterventions- In India, children are elusive of adequate early childhood interventions in the form of immunization, healthy diets, pre-school learning, access to safe drinking water and sanitation etc.
  • Foetal stunting is largely caused by inadequate nutrition of the mother before conception and in the first trimester. However, focus of nutrition programmes for Indian children has largely been post-birth, with child and feeding-centred interventions.
  • School level – Mid day meal scheme pragmatically focusesmore upon hunger and less on providing nutritional diets to India’s future.
• Water, Sanitation and Hygiene (WASH)
  • Access to sanitation reduces cases of diarrhoea, one of the major causes of malnutrition among children, according to this World Bank study.
  • 2% boys, 44.6% of girls with no access to toilets are stunted, compared to 26% boys and 24% girls who live in homes with toilets.
• Migration and food security-
  • Migration is a growing phenomenon in India.
  • The shift in population centers arising from migration has accelerated the triple burden of malnutrition—the coexistence of hunger (insufficient caloric intake to meet dietary energy requirements), undernutrition (prolonged inadequate intake of macro- and micronutrients), and over nutrition in the form of overweight and obesity.
  • Migrants to urban centers face challenges around accessing nutritious food, adequate employment, social protection, housing and, water and sanitation facilities.
• Fragmented data in context of nutrition
  • There is a lot of data available some at the country level, some at the state-level and some more at yet micro-level.
  • But this data is not available at one point to be accessed easily by policymakers to do state specific and region specific interventions.

• Social status and nutrition accessibility
  • An underweight child in India is more likely to belong to a disadvantaged community, such as a scheduled caste or tribe, have an illiterate parents or live in a home without a toilet than other children.
  • Social exclusion prevents scheduled caste and scheduled tribes from accessing government health services and programs and this worsens their health and nutritional status, according to a study.
• Unhealthy lifestyle and food habits – over nutrition (obesity)
  • Lack of physical activity – Overindulgence in indoor leisure activities and enhanced transportation systems.
  • Excess caloric intake– Due to the unrestricted access to energy-dense foods at various platforms like school cafeteria.
  • Lifestyle related factors– Commuting to school by bus or car instead of walking or bicycling, aggressive advertising by transnational fast-food and cola companies are some of the practices which predispose children to obesity.
  • Socio-cultural factors and urbanization– Overprotection and forced feeding by parents, false traditional beliefs about health and nutrition, low knowledge about nutrition in parents and caregivers also contribute to obesity.
• Policy shortcomings
  • Nutrition policies are not area specific and lacks a targeted approach.
  • Convergence between policies though sought in the nutrition scheme, in reality it is still not achievable in spite of the technological advancements.
  • Lack of focus on data and its synchronization.
  • Political commitment and administrative efficiency is not uniform in the country.

Government Schemes to address malnutrition

• Integrated Child Development Scheme (ICDS) : Non-formal preschool education, growth monitoring, supplementary nutrition, health and nutrition education for caregivers
• Mid-day meal scheme (MDM) : Meal to school children with an aim to enhance enrollment, attendance and improve nutritional status
• National Food Security Act, 2013: 75% rural and 50% of the urban population entitled to 5 kg of food grains; rice, wheat and millets at Rs3, Rs2 and Rs1/kg respectively; 600 calories of take home ration for P&LW.
• Zero Hunger Programme, 2017: Organising farming systems for nutrition; set up genetic gardens for bio-fortified plants/crops; Initiate Zero hunger training
• National Nutrition Mission or POSHAN Abhiyan: It strives to reduce the level of stunting (by 2% a year), undernutrition (by 2% a year),anaemia(3% a year) and low birth weight babies (by 2% a year). National Nutrition Mission reflects an amalgamation of scientific principles, political fortitude and technical ingenuity. It highlights a strong focus on convergent actions from the national to the village level.
• Pradhan Mantri Matru Vandana Yojana : It is a maternity benefit program with main focus on immunization of P&LW. Ensuring proper nutrition to mother and children. Financial assistance of Rs. 6000.
• Convergence of various ministries under NNM
• Ministry of Women and Child Development-
  • Anganwadi services
  • Pm MatruVandanaYojana
  • Scheme for Adolescent Girls
• Ministry of Health and Family Welfare-
  • JananiSurakshaYojana
  • National Health Mission
• Ministry of Drinking Water and Sanitation- Swachh Bharat Mission
• Ministry of Rural Development-
  • Mahatma Gandhi National Rural Employment Guarantee Scheme
  • Construction of AnganwadiCentres (AWCs)
• Ministry of Consumer Affairs, Food and Public Distribution- Public Distribution System
• Ministry of Panchayati Raj- Mobilisation of Gram Panchayats towards Convergence
• Ministry of Information & Broadcasting
• Ministry of Tribal Affairs
• Dept. of School Education and Literacy, HRD
• Ministry of Urban development
• Kilkari : Audio messages about pregnancy, childcare, child birth sent to expecting mothers across the nation
• National Nutritional Atlas : The Nutrition Atlas has been developed as a ready reckoner to provide all the data and vital statistics on nutrition for the entire country in a synchronized manner at a click of a button.
• National Nutrition Week: The basic objective of this annual event is to intensify awareness generation on the importance of nutrition for health which has an impact on development, productivity, economic growth and ultimately National development.
• Food fortification
  • Food Fortification is age old, cost effective intervention to address micronutrient deficiencies.
  • Indian government has announced that 118 districts in the country will receive fortified rations, in its attempt to fight widespread malnutrition, especially among women and children.
  • These rations will come in the form of wheat and rice enriched with vitamins and supplements.
  • This is the measure taken under National Nutrition Mission.
  • The two main nutrients that will be added to the food grains supplied by PDS are iron and folic acid.

Consequences of malnutrition

• Impact on health-
  • Malnutrition influences an individual socially as well economically.
  • Malnourished, stunted & weak individuals have lowered self-esteem and confidence.
  • They tend to retreat from society with little or no contribution towards nation building.
  • Malnutrition impairs immunity increasing disease risks & disabilities.
  • Obesity during childhood also causes breathing difficulties, increased risk of fractures, hypertension, and psychological effects. In later life with high chances of obesity, cardiovascular diseases, diabetes can lead to disability and premature death.
• Impact on economy
  • It is estimated that malnutrition can decrease the economic growth of a nation by approximately 8% due to loss in productivity caused due to low energy, lower
  • performance of manual productivity and cognitive impairments.
  • Malnutrition holds the potential to turn our demographic dividend into demographic disaster if it remains unaddressed.
  • The costs of malnutrition have been studied to vary from 2 per cent to 16 percent of GDP depending upon location and sector.
  • Malnutrition perpetuates the cycle of poverty, as poverty-stricken and malnourished mothers have stunted children.

What’s the way forward?

• Research suggests that $1 spent on nutritional interventions in India could generate $34.1 to $38.6 in public economic returns.
• For ensuring sustainable food and nutrition security of the nation, here are some practical policy recommendations:
  • Turn policy focus slightly away from fine cereals to nutri-cereals, pulses, oilseeds, milk, poultry and fish;
  • Include pulses and edible oil under the public distribution system and National Food Security Act;
  • Encourage food fortification; and
  • Raise protein and micro-nutrient content in MDM and ICDS foods.
• If this involves some subsidy, so be it. The long-term economic and social benefits will far outweigh costs.
• For women to become effective decision-makers and have essential reproductive rights they should be socio-economic and politically empowered especially in rural areas.
• Health Infrastructure (PHCs) of rural India needs an overhauling along with establishment of more meaningful communication linkages with local community health workers for enhanced pre & post natal care interventions.

The 5 Essential Nutrition Interventions for Mothers

• Improving the quantity and nutrient level of food consumed in the household
  • Access to generalized household food ration through public distribution system(PDS)
  • Access to supplementary foods under the integrated child development services scheme
  • Access to knowledge to improve the local diet, production and household behaviours through nutrition and health education.
• Preventing micronutrient deficiencies and anaemia.
  • Iron Folic Acid Supplementation deworming
  • Pre and post-conceptual folic acid supplementation
  • Universal access to iodized salt
  • Malaria prevention and treatment in malaria-endemic areas
  • Access to knowledge and support to stop use of tobacco products during pregnancy
  • Maternal calcium supplementation.
  • Maternal vitamin A supplementation
• Increasing women’s access to basic nutrition and health services.
  • Early registration of pregnancy
  • Quality of antenatal natal check-up, with emphasis on pregnancy weight gain monitoring, screening and special care of at-risk mothers
• Improving access to water and sanitation education and facilities:
  • Sanitation and hygiene education, including menstrual hygiene.
• Empowering women to prevent pregnancies too early, too often and too close together:
  • Ensuring marriage at/after legal age of 18 through awareness and ensuring a girl completes secondary education
  • Prevent maternal depletion by delaying first pregnancy and repeated pregnancies through family planning, reproductive health information, incentives and services Maternity entitlement
  • Promoting community support system for women, skill development, economic empowerment
  • Ensuring marriage at/after legal age of 18 through awareness and ensuring a girl completes secondary education and cash transfer
  • Methods to prevent maternal depletion through family planning, reproductive health information, cash transfers, and services
  • Community support system for women to support decision making, confidence building, skill development and economic empowerment.
• Innovative policy interventions like ‘Fat Tax’ (Kerala) can further be deliberated upon to reduce intake of high calorie drinks and foods.
• Consumer awareness regarding consequences of unhealthy diet practices must be made more visible through effective mobilization of communities, celebrities, media and NGO’s.
• A shift from ‘sedentary lifestyle (physical inactivity) to conscious lifestyle’especially among urban dwellers can be factored in through mindful interventions in urban mobility systems and meaningfulpublic nudging.