Urgent Need for Policy Makers and Industry to Collaborate and Address Severe Malnutrition

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Dr Nalini Saligram

Malnutrition is a persistent challenge in India. Despite decades of action, it is still at staggering levels. The Global Hunger Index (2020) — which is estimated based on the total undernourishment of the population — places India at 94 among 107 countries. What is rankling to many working in India’s social sector is that neighbouring countries such as Sri Lanka, Nepal, Bangladesh, Myanmar, and Pakistan have been ranked higher than India on this Index.  

India has the highest number of malnourished children in the world. According to the NFHS 5 report (2019-21), the prevalence of stunting (low height-for-age) in children under five is 35.5 per cent, wasting (low weight-for-height) is 19.3 per cent, and underweight (low weight-for-age) is 32.1 per cent. Comparing the data with the previous NFHS 4 report, the prevalence of stunting, wasting and underweight has slightly reduced but is still extremely high. What is alarming is that there is an 8 per cent increase in children suffering from anaemia – it went up from 59 per cent in NFHS-4 to 67 per cent in NFHS-5.

It is not just young children who are affected. Adolescents and adults suffer badly from malnutrition as well. India has more adolescents than any other country – 250 million, and for this group, the big concern is anaemia. Almost half (40 per cent) of our adolescent girls are anaemic, and 18 per cent of boys (CNNS Thematic Report, 2019). Among adult women (15-49 years), anaemia has increased from 53 per cent to 57 per cent. It is mind-numbing when we contemplate these numbers.

We seem to be going backwards on key indicators, which is a cause for serious concern.  

Stunted growth is an indicator of chronic inadequate nutrition and has serious consequences. It causes irreversible physical and mental damage to children, negatively affects school performance and reduces later adult income generation (UNICEF). Wasting indicates acute undernutrition caused by excessive and rapid loss of muscle mass and strength. These disorders mean that many of India’s children do not thrive and grow up, incapable of contributing to their full potential.  

It is not just young children who are affected. Adolescents and adults suffer badly from malnutrition as well. India has more adolescents than any other country – 250 million, and for this group, the big concern is anaemia. Almost half (40 per cent) of our adolescent girls are anaemic, and 18 per cent of boys (CNNS Thematic Report, 2019). Among adult women (15-49 years), anaemia has increased from 53 per cent to 57 per cent. It is mind-numbing when we contemplate these numbers.

While we always associate undernutrition with malnutrition, malnutrition is a broader term that includes all forms of poor nutrition, including undernutrition and overnutrition. If we examine the double burden of malnutrition in India, we find the connection between severe undernutrition with obesity and non-communicable diseases (NCDs) at different stages of life. 

In a country with so much hunger and poverty, it is ironic that 5 per cent of India’s adolescents are obese, and as much as 37 per cent of urban Indian women are obese. Obesity is a known risk factor for diabetes, heart disease and other NCDs. India is the diabetes capital. Seventy-seven million people are estimated to be diabetic. Up to 75 per cent of adults in metros are diabetic or pre-diabetic. Indians get Type 2 diabetes at the peak of their productive years, in their 30s, some 10-20 years earlier than people in the West. Ten per cent of India’s children, as young as five, are pre-diabetic. This is alarming on all counts.

Unhealthy eating is the number one cause of death. The food we eat has a profound effect on the quality of our lives. According to the Global Burden of Disease Report, salt is the number one dietary culprit for men, while it is low consumption of whole grains for women.

In 2017, India launched POSHAN (Prime Minister’s Overarching Scheme for Holistic Nutrition) Abhiyaan, the country’s flagship national nutrition mission, to bring focus and accelerate India’s longstanding work to improve nutrition. The initiative focuses on reducing the level of stunting, under-nutrition, anaemia, and low-birth-weight babies, by encouraging States to work hard to achieve the targeted goals. More than ten crore people will benefit from this programme.

EAT Forum remarks that converting to healthy diets by 2050 will require substantial dietary shifts. This includes a more than doubling in consumption of fruits, vegetables, legumes, nuts, and a greater than 50 per cent reduction in global consumption of less healthy foods like added sugars and red meat. Fixing our diets will have profound benefits. When we eat right, exercise and avoid tobacco, we can prevent 80 per cent of heart disease, 80 per cent of Type 2 diabetes and 40 per cent of cancers (WHO). 

What is the Government doing about this complex problem? 

India has been trying to address child malnutrition for many decades through various policy initiatives such as: 

  • Integrated Child Development Scheme launched in 1975 
  • National Nutrition Policy 1993 
  • Mid-Day Meal Scheme for school children in 1995 
  • National Food Security Act 2013
  • National Iron Plus Initiative in 2013 to comprehensively address anaemia

In 2017, India launched POSHAN (Prime Minister’s Overarching Scheme for Holistic Nutrition) Abhiyaan, the country’s flagship national nutrition mission, to bring focus and accelerate India’s longstanding work to improve nutrition. The initiative focuses on reducing the level of stunting, under-nutrition, anaemia, and low-birth-weight babies, by encouraging States to work hard to achieve the targeted goals. More than ten crore people will benefit from this programme.

It is also vital that we highlight the incredible achievements of the FSSAI, which has expanded its focus from preventing food adulteration to a more holistic approach to ensure safe and wholesome food for all citizens, their ‘Eat Right India’ movement, and the most memorable series of advertisements – Aaj Se Thoda Kam – which compellingly motivates people, to eat a little less salt, sugar, every day.  

India’s nutritional status, however, is extremely bleak, and we have a long way to go.   

What more can India do? 

India is a vast country, and poor nutrition is widespread throughout the length and breadth of the country. Malnutrition was the predominant risk factor for death in children younger than five years of age in every State of India in 2017, accounting for 68.2 per cent of the total under-five deaths. The most-affected States are Uttar Pradesh, Bihar, Assam, and Rajasthan. They deserve extra attention concerning nutrition programmes.

At this point, the Government must identify districts requiring urgent intervention. It is crucial to empower frontline workers in these districts, train them efficiently, and embed them in the communities so they can teach the people the basics of good nutrition. A recent media article about how a package of eight nutritious local foods, including Tiranga parathas, was used by Anganwadi workers has measurably reduced malnutrition in children in Gadchiroli district in tribal Maharashtra caught my eye. Greater access to healthy nutritious food through public distribution systems is another key part of the puzzle.  

The Government should also prioritise investment in adolescent nutrition. The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) recognises that healthy adolescents contribute significantly to improved school performance, productivity, and economic growth by breaking the intergenerational transmission of malnutrition, ill health, and poverty.

What is needed now is greater political will and collaboration across multiple sectors to confront the complex problem of malnutrition. We also need more investments all around. Research suggests that $1 (Rs 75.08) spent on nutritional interventions in India could generate $34.1 to $38.6 in public economic returns — three times more than the global average. India’s public health agenda is overwhelmingly crowded. It includes non-communicable diseases (NCDs) – the number one cause of death, plus infectious diseases such as TB, under-five childhood mortality, maternal mortality, and the latest – COVID-19 – also demands immediate action but prioritising nutrition is a must. 

How can the private sector and civil society contribute?

The problem is so huge that we must collaborate smartly to deliver a greater impact. One area for action is intervening before the girl child gets pregnant. Low birth weight is a major concern in India and reflects poor maternal nutritional status. This has long-term consequences because low birth weight can lead to an increased risk for diabetes and heart disease later in life when the child grows up. If we can teach the adolescent girl what she must eat and in what quantities at each meal before she gets married and then pregnant, she may be able to have a normal birth weight baby while also reducing the child’s future risk of diabetes. This will also empower her to steer her current and future families towards healthy eating.  

This is the promise of Arogya World’s ‘MyThali’, a tool we have adapted for rural adolescent girls where we use a comic book conversation between two sisters to teach the elements of healthy eating appealingly to that age group. We are finding ways to reach ‘MyThali’ to girls in schools and those outside schools by working with frontline workers. 

There is a lot we can do together – e.g., run a nationwide salt reduction consumer campaign or promote whole grains and millets in our daily diets, or partner to educate consumers to read food labels on packaged foods correctly. It is on my wish list to work with tech experts to get the Aadhar stack or some digital ID to help subsidise fruits and vegetable purchases.  

SDGs and Nutrition 

What is needed now is greater political will and collaboration across multiple sectors to confront the complex problem of malnutrition. We also need more investments all around. Research suggests that $1 (Rs 75.08) spent on nutritional interventions in India could generate $34.1 to $38.6 in public economic returns — three times more than the global average. India’s public health agenda is overwhelmingly crowded. It includes non-communicable diseases (NCDs) – the number one cause of death, plus infectious diseases such as TB, under-five childhood mortality, maternal mortality, and the latest – COVID-19 – also demands immediate action but prioritising nutrition is a must.  

Nutrition is fundamental, and investing in improving nutrition in India is urgent.  

The world is watching India as the country, with 1.38 billion people, is key for the world to meet the Sustainable Development Goals. When we can improve nutrition in India, we can march forward towards Goal 2: End hunger, achieve food security, improve nutrition and promote sustainable agriculture, and go a long way towards Goal 3: Ensure healthy lives and promote wellbeing for all. The need of the hour certainly is to bring together policymakers, State governments, think tanks, big foundations, companies and NGOs to partner and find tangible ways, with focus and intent, to improve nutrition in India. The future of our world depends on this.  

Dr Nalini Saligram is the Founder & CEO of Arogya World, an Ashoka Fellow.