Bridging the Malnutrition Gap | 07 Sep 2023

As India has entered into the Amrit Kaal (the 25-year-long leadup to India@100) , there is much to be proud about; significant advances have been made in science, technology, and medicine, adding to the country’s ancient, traditional, and civilisational knowledge base, wisdom and wealth.

Still, it is disconcerting that even after seven decades of Independence, India is afflicted by public health issues such as child malnutrition. Poor nutrition not only adversely impacts health and survival but also leads to diminished learning capacity, and poor school performance. And in adulthood, it means reduced earnings and increased risks of chronic diseases such as diabetes, hypertension, and obesity.

What is Malnutrition?

• Malnutrition refers to deficiencies or excesses in nutrient intake, imbalance of essential nutrients or impaired nutrient utilization.
• The double burden of malnutrition consists of both undernutrition and overweight and obesity, as well as diet-related noncommunicable diseases.
• Undernutrition manifests in four broad forms: wasting, stunting, underweight, and micronutrient deficiencies.
  • Wasting: It is defined as low weight-for-height.
    • It often indicates recent and severe weight loss, although it can also persist for a long time.
    • It usually occurs when a person has not had food of adequate quality and quantity and/or they have had frequent or prolonged illnesses.
    • Wasting in children is associated with a higher risk of death if not treated properly.
  • Stunting: It is defined as low height-for-age.
    • It is the result of chronic or recurrent undernutrition, usually associated with poverty, poor maternal health and nutrition, frequent illness and/or inappropriate feeding and care in early life.
    • Stunting prevents children from reaching their physical and cognitive potential.
  • Underweight: It is defined as low weight-for-age.
    • A child who is underweight may be stunted, wasted or both.

To What Extent is India Affected by the Issue of Malnutrition?

• According to Worldometer, India is the largest contributor of undernourished people in the world, with around 14.37% of its population not receiving enough nutrition.
• As per the Government’s National Family Health Survey 5 (NFHS 5):
  • 36% of children under age five years are stunted
  • 19% are wasted
  • 32% are underweight
  • 3% are overweight
• Anemia, also referred to as low hemoglobin; affects a staggering 67% of children below the age of 5 years.
• Anemia is much more prevalent in women, as a hefty 57% of Indian Women suffer from it, compared to the relatively low 25% of Men in India (Under 50 years).
• Moreover, 19% of Women and 16% of Men under 50 are undernourished, while 24% of Women and 23% of Men are victims of obesity.
  • Approximately 40% of the humongous population of 1.4 Billion is malnourished.

What are the Primary Causes behind prevailing Malnutrition in India?

• Economic Inequality: Due to the low economic status of some parts of the population, their diet often lacks in both quality and quantity. Poor people often cannot afford nutritious food or have limited access to it. They also face food insecurity due to natural disasters, conflicts, or price fluctuations.
• Lack of Primary Health Infrastructure: Many people in India do not have access to basic health services, such as immunization, antenatal care, or treatment of infections. This increases the risk of diseases and complications that can worsen malnutrition.
  • The WHO recommends a doctor to population ratio of 1 per 1000 and an ideal nurse density of 3 per 1000 people. In India, there are 0.73 doctors and 1.74 nurses per 1000 people.
• Lack of Awareness and Illiteracy: Many people in India are not aware of the importance of nutrition or the best practices to ensure it. They may not know how to prepare balanced meals, what foods to avoid during pregnancy or breastfeeding, or how to prevent micronutrient deficiencies. Illiteracy also limits their ability to access information and education on nutrition.
• Weak Public Distribution System (PDS): The PDS is a government program that provides subsidized food grains and other essential commodities to poor households. However, the PDS suffers from many problems, such as corruption, leakage, diversion, poor quality, and inadequate coverage. As a result, many people who need food assistance do not receive it or receive insufficient amounts.
  • According to a report by the CAG, only 49% of the food grains allocated under the PDS reached the intended beneficiaries in 2012-13.
• Poor Implementation of Integrated Child Development Scheme (ICDS): The ICDS is another government program that aims to improve the nutrition and health of children under six years old and pregnant and lactating women. The ICDS provides supplementary food, health check-ups, immunization, growth monitoring, and pre-school education through anganwadi centres (community-based mother and child-care centres).
  • However, the ICDS also faces many challenges, such as inadequate funding, staff shortage, low quality of services, and low participation rates.
  • According to the NFHS-5, only 50.3% of children under six years received any service from an anganwadi centre in the last 6 months.
• Poor Sanitation: Poor sanitation and hygiene practices can increase the exposure to pathogens and parasites that can cause infections and diseases. These can affect the absorption and utilization of nutrients in the body and lead to malnutrition.
  • The NFHS-5 found that only 69% of households use an improved sanitation facility.

What More should be Done?

• Develop a Focused SBCC Action Plan: States should collaborate to develop a well-structured and focused Social and Behavior Change Communication (SBCC) Action Plan specifically tailored to address malnutrition. This plan should outline the objectives, target audience, key messages, and strategies for effective communication.
• Institutionalize Nutrition Counseling: Nutrition counseling should be institutionalized as a fundamental component of the healthcare system. This means integrating it into existing healthcare infrastructure, such as primary health centers and community health programs, to ensure that it becomes a routine part of healthcare services.
• Raise Awareness on Exclusive Breastfeeding (EBF): Emphasize the importance of exclusive breastfeeding during the first six months of a baby's life. Launch awareness campaigns that educate mothers and families about the benefits of EBF, including optimal techniques for holding, latching, and manually emptying the breast for better milk transfer.
• Antenatal and Postnatal Breastfeeding Counseling: Implement a systematic approach to provide breastfeeding counseling to pregnant women during antenatal checkups and continue this support through frequent home visits after delivery. Evidence suggests that such counseling significantly improves breastfeeding practices and reduces undernutrition.
• Complementary Feeding Practices: Address the gap in complementary feeding practices by educating parents and caregivers on when to start complementary feeding (around six to eight months), what and how to feed, frequency, and appropriate quantities. Make this information accessible to all socio-economic groups.
• Prime Minister's Involvement: Engage the Prime Minister to provide strong support and visibility to nutrition programs, similar to initiatives like Swachh Bharat Abhiyaan, through platforms like 'Mann Ki Baat.' This can help in mobilizing resources and generating public awareness.
• Revise and Overhaul POSHAN 2.0: Reevaluate the implementation of the POSHAN 2.0 program to identify and rectify any flaws. Ensure that the system is effectively reaching mothers and children during the critical first 1,000 days of life.
• Exploration of Alternative Distribution Channels: Consider distributing supplementary nutrition, such as Take-Home Ration packets, through the Public Distribution System (PDS) to free up anganwadi workers for counseling. This can streamline the delivery of essential nutrition to beneficiaries.
• Combine Human Resources: Develop and test a new system that integrates the human resources of the Integrated Child Development Scheme (ICDS) and the healthcare system, from the village to the district and state levels. This would create a more efficient and accountable system for delivering services during the first 1,000 days of a child's life.
• Utilize Mass Media: Leverage mass media and television shows to organize informative discussions and discourses on caring for infants and young children during the first 1,000 days. This can reach mothers and caregivers beyond the public health system.
• Continuous Monitoring and Evaluation: Establish a robust system for monitoring and evaluating the effectiveness of these interventions, making necessary adjustments based on the results to ensure the sustained reduction of child malnutrition.

What Lessons Can be learnt from Bemetara Village?

• Bemetara in Chhattisgarh is a district where the number of Severe Acute Malnutrition (SAM) children there was as high as 3,299 in December 2022.
  • There was a lack of proper knowledge about feeding practices. This is why nutrition counseling combined with robust monitoring was chosen as the modus operandi for this area.
• Potth Laika Abhiyaan (Healthy Child Mission) is a nutrition counseling programme that is being implemented in 72 of the most affected AWCs.
  • Ground-level staff from the Health and Women and Child Development departments have been well trained on how to provide nutrition counseling in the region.
  • Every Friday, the parents of the targeted SAM and Medium Acute Malnutritioned (MAM) children are summoned and counseled.
    • They are taught in simple Chhattisgarhi language the importance and the constituents of “Tiranga Bhojan” (a balanced diet), the need to wash hands regularly and many other tips in order to lead a healthy lifestyle.
    • The progress of the targeted children is being monitored.
  • Local leaders such as Sarpanchs, Panchayat sachivs and religious heads have also participated in the counseling sessions.
  • Door-to-door visits to the houses of targeted children are also done to monitor their progress.
  • As a result of the simple mantra of nutrition counseling along with regular monitoring and evaluation, as many as 53.77% of targeted children were brought out of malnutrition, in a span of nine months.
    • When comparing this with a random control group of 20 AWCs where this mission was not being implemented, only 30.6% children were taken out of malnutrition.
  • This mission is a zero cost one, requiring no more than a few training sessions and regular monitoring. Thus, it has shown itself to be cost effective as well.