People of India need better nutrition, not free ration

With 46.6 million stunted children and 25.5 million wasted children, India contributes to the highest global burden of undernutrition and has the fifth-highest prevalence of underweight children and third-highest prevalence of wasting of children on the global map.

Despite the much touted “Anna Vitran Yojna” which helped the BJP retain power in UP, it is clear that India doesn’t fare well in terms of providing nutrition to its citizens.

The recent National Family Health Survey (NFHS-5) shows worsening of parameters related to malnutrition among under-5 children, with an increase in wasting (low weight for height) in states like Bihar, Telangana, Kerala and Assam. Stunting (low height for age) has increased in states like Telangana, Kerala, Himachal Pradesh and Goa. The proportion of underweight children in Maharashtra, Gujarat, West Bengal, Telangana, Kerala and Assam have also significantly increased.

These parameters turned even worse due to Covid-19 pandemic and lockdowns which impacted access to nutritional requirements and the targets of the overarching POSHAN Abhiyan schemes. Covid-19 has tested our food systems, already stressed by climate extremes.

Interruptions in community outreach programs like Jan Andolan activities, immunisation sessions, limited resources as well as ever-increasing poverty and the accompanying price rise of commodities played a direct role in nutritional parameters deteriorating in the country.

The Global Hunger Index 2021 showed that despite spending millions on holistic schemes for nutrition, India stood at an alarming rank of 101. Although health and its coverage improved in recent years, the progress has been inequitable.

According to NFHS-5, India still has 35.5% children under 5 years of age as stunted, who are disproportionately distributed across the urban and rural communities, geography, age groups, gender and socio-economic strata.

Globalisation, urbanisation, climate shocks and emergencies are worsening the nutritional prospects of millions of poor and socially excluded children.

Malnutrition among children

The world is turning more urbanised and among the many challenges are overcrowding, limited access to basic health services, poor housing standards, unsafe water, and inadequate hygiene and sanitation. Hidden hunger, defined as the deficiency of vitamins and minerals, has impacted child mortality for decades and remains a matter of concern for 200 million people worldwide despite various efforts in food supplementation and fortification.

According to the Comprehensive National Nutrition Survey 2016–2018, the prevalence of vitamin A deficiency was 18% among pre-school children, 22% among school-age children whereas Vitamin D deficiency was found among 14% of pre-school children and 18% of school-age children.

Young children and pregnant women are the most vulnerable groups in the population and malnutrition not only affects the cognitive development of a child but is also a major contributor in child mortality in India.

With only 50% infants receiving exclusive breastfeeding and complementary feeding at 6 months, Infant and Young Child Feeding (IYCF) practices, which shape the nutritional status of children and impact child survival and development outcomes in the long term, are seen to be compromised in the community.

The NFHS-5 reports a drastic figure: only 11% of total children aged between 6-23 months receive an adequate diet following the IYCF guidelines for feeding. The feeding quality and quantity is impacted by community they live in, mother’s age and parity, parent’s education, family wealth, hygiene practices, sanitation as well as the birth order and birth weight of the child.

Nutrition is a multidimensional concept with varied factors affecting it. NFHS-5 also reported that 35% under-5 children are stunted in India, with major burden on the northern states.

The figure of 32% children under-5 years of age being underweight puts light on the outcome and impact of an ambitious programme like Poshan Abhiyan.

It recently upgraded to Poshan Abhiyan 2.0, with new focus on more outreach to 112 aspirational districts and innovation in technology with Poshan Tracker Software. The Poshan Tracker, which was known as ICDS-CAS (Integrated Child Development Services-Common Application Software) in the earlier version of the program, was launched with the similar aim of tracking and thereby improving the services delivered at the Anganwadi centres.

This high budget real-time monitoring system was one of the major essences of Poshan Abhiyan through Poshan Tracker which failed to provide any useful information regarding the nutrition status of the beneficiaries and the impact of the program.

It only provides the administrative data like vaccination given, hot cooked meals and take-home rations given in the last 30 days and the number of beneficiaries registered at the Anganwadi centres daily.

The data is available district-wise, which shows no critical data of the program and no inferences can be made on the nutritional status and the indicators to predict the prevalence of malnutrition.

Allocation and underutilisation of funds under Poshan Abhiyan is questionable, especially for poor performing states. Utilisation of 56% funds by the states is a challenge when this program aims to reach the aspirational districts.

India’s progress in achieving Sustainable Development Goal 2 to end hunger is slow and is impacted by the rising costs of a healthy diet and inability to afford rice, wheat and other agriculture produce.

As a result, the average per capita consumption of energy among the poorest in the population is 33% deficit in calories against the Estimated Average Requirement of 2110 Kcal/day.

In states like Bihar (48%) and Uttar Pradesh (46%), almost one in two children are stunted and India has the second highest number of stunted children in South Asia after Afghanistan.

Stunting and wasting have long term impact on the economic productivity of a nation, leading to more spending on health and poverty, reduced school enrolment and increased dropouts.

The burden of NCDs

The triple burden of malnutrition involving non communicable diseases (NCDs) due to increased prevalence of obesity is becoming a major public health concern globally and in urban areas in particular.

According to NFHS-5, 16 states/UTs showed significant increase in percentage of overweight children below five years of age like Maharashtra, Gujarat, Mizoram, Tripura, Jammu and Kashmir, Lakshadweep, and Ladakh.

India on one hand runs the risk of malnutrition as well as an epidemic of obesity and other non-communicable diseases related to poor nutrition like diabetes mellitus.

According to Comprehensive National Nutrition Survey 2016–2018, India has already witnessed 10.3% of school-age children and 10.4% of adolescents as pre-diabetic. Alarming figures of NFHS-5 show the prevalence of obesity among 24% women and 22% men.

A new indicator of obesity, namely waist-hip ratio, has put 56.7% women and 47.7% men in the high-risk category which is equally higher in both rural and urban populations.

A remarkable shift in urban diet and food systems like ultra-processed food and beverages, sedentary lifestyle, ever elaborating technology, access to fast foods, empty calorie intake and leisure have been the major contributors.

The risk of obesity can be passed from one generation to the next as a result of behavioral and biological causality which makes it important to be aware of the triple burden of diseases. Thus, it’s important to approach the problem comprehensively for sustainable development with aspirational aims of eliminating malnutrition with zero hunger by 2030.

The scourge of anaemia

Anaemia is matter of concern across all age groups, genders and communities. More than 50% women in reproductive age group suffer from anaemia in India. With other setbacks such as gender disparity, early marriage etc often leading to maternal undernutrition which also affects child nutrition at proportionate levels, this needs an intervention in the form of lifecycle approach.

In a similar way, under- 5 children suffer from anaemia, accounting to an enormous figure of 67%. Although the issue of anaemia is beyond the disparities of socio-economic status, faulty feeding practices are an addition to the causes.

Data from ‘Anaemia Mukt Bharat’ clearly shows that a meagre number of 10-15% children under 5 years of age receive prophylactic Iron Folic Acid doses. A mission which claims to make India anaemia-free by 2022 clearly has large gaps to fulfil.

Reduced financial efficiency and unregulated allotment and distribution of resources have also played major role in the poor performance of the states. Under the budget gap analysis of Anaemia Mukt Bharat, most states did not budget for important assets of the program like research & innovations, drug & warehouse logistics and human resource development. This hampered the essence of the program’s 6x6x6 strategy.

The way forward

Nutrition goes way beyond food security. A combined effort is awaited to promote and establish healthy childhood which will improve the demographic dividend of the country, leading to a healthy workforce and increased productivity of the country.

What is needed:

• Identification of high-priority districts based on anthropometry and nutritional assessment is the need of the hour, alongside their analysis across communities for more comprehensive intervention and follow-ups without delays.

• Ensuring food security through Public Distribution System (PDS), dietary diversification, food fortification with emphasis on bio fortification measures.

• Social inclusion of the marginalised as well as priority households and beneficiaries, accessibility to primary healthcare for a motive of inter-sectoral convergence is the need of the hour. Also, a robust quality data management system for policy building and management are important too along with more efficient Behavioural Change Communication with community involvement and participation in identifying their needs and finding solutions.

• Importance of exclusive breastfeeding, infant and young child feeding practices, importance of immunisation, deworming, antenatal and postnatal care, hygiene and sanitation are the various themes for IEC activities, Jan Andolan and community-based events, which need urgent attention.

• Capacity building and utilisation of funds for training should be regulated and monitored too. High aiming programs like Anaemia Mukt Bharat needs to track funds and resources disbursement and improve expenditure efficiency of the states as many reported inadequate funds allotted, which also brings into light the importance of fund allotment according to the beneficiaries in the states and districts. And hence, improve by identifying major financial gaps and evaluation of the program targets.

• The quality of data needs improvement with inclusion of key indicators on Poshan Tracker, to study the impact of the program along with real time monitoring. Also, one-sided focus on the reproductive age group women with anemia should widen up, look upon the under 5 children who face the burden of poor feeding practices, inadequate diet as well as very limited coverage of the beneficiaries under the program.

Despite various efforts and changes in such holistic national programmes like POSHAN 2.0, Saksham Anganwadi, Food Security Act, Anaemia Mukt Bharat, expansion of Anganwadis under ICDS and mid-day meal schemes, the situation still stands grave.

(Views are personal)