Tackling malnutrition in India

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India is among those countries in the world with the highest recorded numbers of undernourished and malnourished people. As the country aspires to fulfil its economic and social development goals, how will we solve this humongous problem?

India, a progressive nation is said to have immense potential to lead the world in many ways. Its science and technological advancements, infrastructure development, burgeoning business environment, increasing foreign relations and trade collaborations, growing political influence over many emerging markets, education and lifestyle progress have all been great contributors to its growth story. Howbeit, experts believe that the disparity in health economics can act as a serious deterrent to this progress. Disparity in terms of rural-urban health infrastructure, differentiating health indices within states, rising NCDs, disproportionate nutrition level, varying social determinants that impact health outcomes, etc., are poignant concerns.

Amongst these, nutrition related conditions such as under-nutrition—obesity and malnutrition is said to be a major cause of concern that stunts India’s economic growth ambitions.

Socio-economic impact of malnutrition

Ironically, in our country we have both forms of malnutrition- under nutrition and overweight obesity and as per various studies, and expert reviews both these forms co-exist with multiple micronutrient deficiencies.

For instance, India houses  the second highest number of obese children in the world at  14.5 million after China, which  has 57 million. Also, we have the highest population of stunted (low height for age) kids – 48.2 million. Similarly, statistics compiled by the Food and Agricultural Organisation (FAO) show that while the Sub-Saharan countries of Africa have the highest prevalence of hunger, in absolute terms, India has the highest number (one quarter) of undernourished (hungry) people in the world (194.6 million or 15 per cent of India’s total population during 2014-16).

In 2015-16, 38.4 per cent of Indian children below the age of five were stunted, according to National Family Health Survey data. States which are having high malnutrition (Children under five years who are stunted) rates are Bihar (48.3 per cent) , UP (46.3 per cent), Jharkhand (45.3 per cent), Meghalaya (43.8 per cent), Madhya Pradesh (42 per cent), D&N Haveli (41.7 per cent) and Rajasthan (39.1 per cent).

Moreover, every one per cent loss in adult height due to childhood stunting is associated with a 1.4 per cent loss in economic productivity and stunted children earn 20 per cent less as adults compared to non-stunted individuals, as per IndiaSpend reported in July 2016.

Therefore, loss of human potential means a a huge economic loss to the country. Dr Shweta Khandelwal, Associate Professor, PHFI and Senior Public Health Nutritionist and member of FSSAI informs, about a UNICEF report that reveals, stunting in early life is linked to 0.7 grade loss  in  schooling, a seven-month  delay in starting school and between 22 and 45 per cent reduction in lifetime earnings. The Global Nutrition report 2016 pegged malnutrition related economic losses to be around 11 per cent of GDP per year in Asia. It has been estimated that because of undernutrition, India will suffer an economic loss of about $40 billion by 2030, which might perhaps be the highest loss of human potential ever.

Malnutrition has an enormous effect on the socio-economic aspects within the country as well. For example, Dr Khandelwal points outs, “The first 1000 days (conception to two years of age) are very crucial to curtail malnutrition. Thus, factors like poverty, social taboos, unhealthy diets, poor access to healthcare, lack of education, financial dependency etc., exacerbate the malnutrition effect on an individual. It is estimated that half of all child stunting occurs in utero. In general, malnourished women and girls of reproductive age have higher chances of giving birth to smaller babies (weight and height), continuing the cycle of malnutrition into future generations. Child stunting also impacts brain development and results in impaired motor skills.”

Dr Rajan Sankar, Program Director- Nutrition, TATA Trusts, propounds,“Poverty and undernutrition are locked in a vicious cycle of increased mortality, poor health, and retarded cognitive and physical growth, diminished learning capacity and ultimately lower work performance, productivity and earnings. As this vicious cycle threatens health and survival, it simultaneously erodes the foundation of economic growth — peoples’ strength and energy, creative and analytical capacity, initiative and entrepreneurial drive. It is right to say that malnutrition slows economic growth and perpetuates poverty. Mortality and morbidity associated with malnutrition also represent a direct loss in human capital and productivity for the economy. The effects of malnutrition are long-term and trap generations of individuals and communities in the vicious circle of poverty. Improving nutrition is therefore essential to eradicate poverty and accelerate the economic growth of low- and middle-income countries.”

Sharing the experience from MSF’s Darbhanga project, officials inform that out of over 14,000 children under five treated in, 87 per cent belonged to the poorest and the most marginalised castes and more than 60 per cent were found to be female thereby indicating a distinct social and gender slant in those suffering from malnutrition. The MSF team also observed that breastfeeding practices varied across cultures.

Understanding the cost of malnutrition

Malnutrition also adds to overall healthcare costs to a patient and his family as well as the country at large. Experts explain how malnutrition amounts to human and healthcare cost. Dr B Sesikeran, Former Director, National Institute of Nutrition (ICMR), FSSAI says, “Due to long-term illness and prolonged medication expenses caused by malnutrition, parents of malnourished children have to constantly spend a lot of money on medicines and healthcare services driving them into poverty.

“In India, it has been estimated that the economic cost of micronutrient malnutrition amounts to between 0.8 per cent and 2.5 per cent of GDP.” Referring to a Cost of Hunger in Africa (COHA) report, he says, “The cumulative effects of malnutrition lies in its grave impacts on cognitive and physical development of children as well as medical costs. The costs of malnutrition have been studied to vary from two per cent to 16 per cent of GDP depending upon location and sector.”

He explains further, “As per an analysis based on surveys by the National Nutrition Monitoring Bureau during 1988-90 and 1996-97, it is indicated that 30 per cent of households in India consume less than 70 per cent of energy requirement. This was based on the presumed parameter of an average wage of Rs 60 per Indian per day for eight hours of work. Therefore, work hour lost per day per person because of inadequate calorie consumption was four hours of moderate work and 7.5 hours of heavy work. Loss of money because of malnutrition related low productivity was approximately Rs 30 per day per person. Direct nutrition interventions, such as promoting breastfeeding, and indirect nutrition interventions, such as social protection, investments in agriculture, and ensuring access to safe water and sanitation, can address malnutrition’s underlying causes. Hence, investing in nutrition is key to unlock the potential of a generation of children.”

Expounding on the interrelation between improved nutrition and economic growth and its significance to understand human and economic development, Dr Sankar says, “It is a two-way relationship. On one hand, an inclusive economic growth that can contribute towards reductions in the prevalence of malnutrition and on the other hand, reductions in malnutrition can have a transformative effect on economic potential of individuals and whole society. The World Bank suggests that malnutrition results in 10 per cent lower lifetime earnings. It is estimated that each dollar spent on nutrition delivers between $8 and $138 of benefits and another study shows that preventing one child from being born with a low birthweight is worth $580.23. According to the Copenhagen Consensus, ensuring good nutrition is the single most important, cost-effective means of advancing human well-being and advancing on the Millennium Development Goals. Evidence suggests that improved nutrition not only drives stronger economic growth but is tremendous value for money,” Sankar adds.

Eliminating malnutrition needs a multi-pronged approach

The government in the past and is at present continues to initiate efforts to control malnutrition in many ways. The national schemes/ programmes include the Integrated Child Development Services (ICDS), National Health Mission (NHM), Mid-Day Meal Scheme, Rajiv Gandhi Schemes for Empowerment of Adolescent Girls (RGSEAG) namely SABLA, Indira Gandhi MatritvaSahyogYojna (IGMSY) as direct targeted interventions. Besides, indirect multi-sectoral interventions include Targeted Public Distribution System (TPDS), National Horticulture Mission, National Food Security Mission, Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS), Swachh Bharat Abhiyan, National Rural Drinking Water Programme etc.

Mentioned below are the  good initiatives taken by some states:

Gujarat: The state has already implemented various schemes like Chiranjeevi Yojana, Bal Bhog Yojana, Vitamin Yukta Poshan Ahar Yojana (nutritious food with vitamins), Kanya Kelavani Yatra for saving the precious lives of mothers and children, fighting against malnutrition, taking care of primary education and particularly education of girl child. In order to improve the current status of nutrition, it was felt that the preventive and curative strategy needs to be very clearly evolved keeping in view the various stages of desirable interventions namely adolescence, nine months of pregnancy to first two years of age (critical 1,000 days) and for children up to six years. Hence, the Gujarat State Nutrition Mission was formulised.

Following are the preventive aspects of Gujarat state nutrition mission

  • Acceleration community mobilisation for strengthening comprehensive nutrition programme through extensive behaviour change communication (BCC)
  • Strengthening ongoing nutrition supplementation programmes through MAMA diwas and Annaprashan Diwas
  • Strengthen infrastructure of intensive nutrition care centre as “ganishth poshan abhiyan Kendra,” child malnutrition treatment centre as ‘bal sewa Kendra’ and nutrition rehabilitation centre ‘Bal Sanjeevani Kendra.’

Other programmes and schames to tackle malnutrition in the state are

  • Bal Shaka Scheme
  • Bal Amrutam
  • Kasturba Poshan Sahay Yojna
  • Mission Balam Sukham
  • Mamta Ghar
  • Doosh Sanjeevni Yojan
  • Mission Shakti

Rajasthan: In Rajasthan, a joint-initiative of the departments of Women and Child Development, and Medical and Health, with technical support from UNICEF – Rajasthan, the Rajasthan State Nutrition Mission called for convergence of all concerned departments and sectors actively involved in addressing the multiplicity of causes and the multiple determinants of nutrition. Planned in a phased three-year approach (2006-08), in the first phase, the mission focussed on 13 districts, including five with tribal predominance, followed by the remaining 19 districts.

The community-based Management of Acute Malnutrition (CMAM)— a project undertaken by the government in December 2015 — has helped to treat 9,117 children below five years who were suffering from severe acute malnutrition (SAM).

India with a large population that still living in accute poverty needs a multi-pronged approach to tackle malnutrition. According to Médecins Sans Frontières (MSF) the following can be done:

Give priority to the 1000-day period: A child’s first 1000 days since birth are critical for his/her survival, growth and intellectual development. This is also a period when the child can potentially suffer from problems like infections or diarrhoea or is underweight. During this period, breastfeeding practices play a vital role in preventing infections and ensuring child survival. Breast milk is the best source of nutrition and immunity for a newborn infant, especially during the first six months of its life.

Prevention vs treatment: It is crucial that programmes to treat malnourished children are not considered a solution that removes the need to take preventive strategies seriously. It should not be a choice between preventive strategies versus those that offer medical treatment. Malnutrition cannot be eliminated without adequate information, awareness and preventive measures.

Need for credible data and evidence: Collecting reliable data can help understand the prevalence of undernutrition. This would mean investing in obtaining appropriate data including regular nutrition surveillance at the district level. As mentioned before, among the over 14,000 children (under five-year-old) treated, 87 per cent belonged to the poorest and the most marginalised castes and more than 60 per cent were found to be female thereby indicating a distinct social and gender slant in those suffering from malnutrition. This kind of nuanced information is of immense value for generating awareness, planning appropriate interventions and sharing information.

More than just health: Nutrition needs to be considered while devising policies for food security, agriculture as well as water and sanitation apart from just being addressed within health. This is important to address critical problems such as, what happens to severely malnourished children when after treatment they go back to the same environment of chronic food insecurity. Understanding the link between health, social welfare and community perception can play a valuable role in the success of malnutrition programmes.

Investing in the community: MSF’s experience in Darbhanga has taught them that communities are the most vital in implementation of malnutrition projects. Community health workers help us bridge language and cultural barriers with the community and make treatment more accessible. Empowering the community with information can reinforce the importance of addressing malnutrition and make them partners in successful implementation of programmes. While malnutrition is a national problem, it is critical to engage with community resources and knowledge at the most grassroot level.

Investment in health sector: The Integrated Child Development Services (ICDS) system is like the central nervous system of all nutrition programmes and strategies. The ICDS, which comes under the Ministry of Women and Child Health, cannot singularly be tasked with this burden of reducing malnutrition since it is overburdened, underfinanced and poorly managed. What is important is to invest in nutrition as a priority, by allocating resources or providing institutional mechanisms to combat the problem of malnutrition. The national nutrition mission was framed in 1993, followed by more guidelines and specific policies. There is a need to review these policies in today’s context and developments, while at the same time holding the government accountable to the implementation and political commitments around nutrition financing and governance.

Additionally, Dr Khandelwal recommends nutrition specific interventions.  “Women education and empowerment as well as their financial independence are important areas. There are three main segments which need to be acted upon simultaneously – nutrition specific interventions (feeding programmes, access to healthy foods, breastfeeding etc); nutrition – sensitive interventions (like women empowerment, education, agriculture, sanitation) and enabling environment (like governance, subsidies, tax reforms, policy etc). We can’t focus on only one dimension and expect any sustainable development or progress in getting rid of malnutrition. This framework dovetailing all three pillars of action against malnutrition need to be recognised and implemented in harmony. For this decision makers, bureaucrats, academia/ researchers and programme implementers need some level of capacity building in their respective areas of work. We also need motivated and trained front line health workers for effective action against malnutrition,” she informs.

Equivalently, Dr Sankar cites from a 2013 report published by Food and Agriculture organisation of the United Nations that examines the cost of malnutrition and ways to resolve the cost issue. India can take some learnings from this report as well. The report says, “The cost of malnutrition is high, but investing in solutions can improve nutritional outcomes long term. Recent research shows that investing $1.2 billion annually in micronutrient supplements, food fortification and biofortification of staple crops for five years would generate annual benefits of $15.3 billion, a benefit-to-cost ratio of almost 13 to 1, and would result in better health, fewer deaths and increased future earnings (SOFA 2013).” (http://www.fao.org/zhc/detail-events/en/c/238389/)

Can nutrition fortification be an answer?

In many ways, experts agree that nutrition fortification is a good way to enhance nutrition related interventions.

“Food fortification refers to the addition of micronutrients to processed foods. In many situations, this strategy can lead to relatively rapid improvements in the micronutrient status of a population, and at a very reasonable cost, especially if advantage can be taken of existing technology and local distribution networks. Since the benefits are potentially large, food fortification can be a very cost-effective public health intervention. Fortification of food with micronutrients is a valid technology for reducing micronutrient malnutrition as part of a food-based approach when and where existing food supplies and limited access fail to provide adequate levels of the respective nutrients in the diet. In such cases, food fortification reinforces and supports ongoing nutrition improvement programmes and should be regarded as part of a broader, integrated approach to prevent micronutrient malnutrition MNM, thereby complementing other approaches to improve micronutrient status,” states Dr Sankar.

In a manner corresponding to the FSSAI, food fortification has a high benefit-to-cost ratio. Likewise, Copenhagen Consensus- a project that seeks to establish priorities for advancing global welfare using methodologies based on the theory of welfare economics estimates that every one rupee spent on fortification results in 9 Rupees in benefits to the economy. “It requires an initial investment to purchase both the equipment and the vitamin and mineral premix, but the overall costs of fortification are extremely low. Even when all program costs are passed on to consumers, the price increase is approximately by 1-2 per cent, which is less than the normal price variation”, explains Dr Khandelwal.

Following are the benefits of fortification of foods according to FSSAI:

  • Nutrients are added to staple foods since they are widely consumed. Thus, this is an excellent method to improve the health of a large section of the population, all at once.
  • It is a safe method of improving nutrition among people. The addition of micronutrients to food does not pose a health risk to people. The quantity added is small and well under the Recommended Daily Allowances (RDA) and are well regulated as per prescribed standards for safe consumption.
  • It is a cost-effective intervention and does not require any changes in eating patterns or food habits of people. It is a socio-culturally acceptable way to deliver nutrients to people.
  • It does not alter the characteristics of the food like the taste, aroma or the texture of the food.

Food fortification practice in India

Currently, food fortification is endorsed and supported by governments as well as by international agencies such as the World Health Organization (WHO), the Food and Agricultural Organization of the United Nations (FAO), and the United Nations Children Fund. Staple foods including salt, flour, oil, rice and sugar are the main vehicles chosen for this application. India too has  acknowledged this and set requirements for the fortification of staple foods. Following publication of a draft regulation in October 2016, which failed to include mention of a product known as ‘standardised milk’ the text was updated and a new version of the regulation published on May 19, 2017. (Refer to the Table 1: Food fortification by FSSAI in 2017)

“The government in future is also planning to roll out a strategic phased operation in order to make its nutrition programmes more efficient. The first phase of the endeavour will focus on public funded food programmes which will include supplying fortified food and scale up the programme to various regions and the second will focus on opening market channels through effective communication and public awareness,” disclosed Dr Khandelwal.

Besides this, Dr JB Prajapati, Principal & Dean, Faculty of Dairy Science, SMC College of Dairy Science, Anand Agricultural University, speaks about the need to promote fermented food products which are natural and can be prepared and supplied at a low cost. “Fermentation is a natural process  and has more nutritional value. For example, when milk is fermented into curds, you will find that curds are more nutritional than milk. Going this route will also save us cost on  buying fortified food. At our institute in Anand, Gujarat we have developed an  iron fortified butter milk which is rich in nutrients such as iron, fibres and vitamin C and can be made easily available to school going children especially young girl. We are soon going to come up with a booklet of such fortified food stuffs which can even be prepared at home,” he said.

The role of private sector in supplying fortified foods

Well, no endeavour can be complete without the efforts of its multiple stakeholders and the private sector indeed plays an important role in the supply of fortified food. The FSSAI has taken initiative to promote food fortification and with its efforts a number of enterprises have begun adding premixes of micronutrients to launch fortified foods. Dr Sankar reveals, “Big enterprises like General Mills India, ITC, Hindustan Unilever and Patanjali will launch wheat flour and Adani Wilmar, Marico, Borges India, and Kaleesuwari Refineries are working on oil whereas LT Foods, DCP Food and KKR Food will launch rice products.   Other brands will join Tata, which already has a double fortified brand in the salt segment. Milk cooperatives in Haryana, Punjab, Rajasthan, Assam and Maharashtra are fortifying their products too. Targeting children, Rajasthan, Madhya Pradesh, Haryana and Himachal Pradesh governments have begun using fortified oil for their mid-day meal schemes. West Bengal and Andaman and Nicobar Islands are now distributing fortified wheat flour through public distribution system, and Maharashtra government has already started a pilot project. Recently, the key Ministries- Women and Child Development, Human Resource Development Departments, and Consumer Affairs, Food and Public Distribution have issued guidelines to provide fortified foods: Oil, wheat flour and double fortified salt through the ICDS, MDM and PDS.”

A strategy that is well meaning

The government is doing its bit. As per an industry source, the government will come up with guidelines for CMAM (Community-Based Acute Malnutrition Model) to tackle this issue. The private sector as well is extending its efforts in this space; however, the fact remains that malnutrition cannot be resolved just by fortifying food-stuff. It needs a 360 degree approach.

“Food fortification is just one aspect to tackle malnutrition, the country certainly requires a multi-pronged approach wherein all aspect of this condition and situation is covered. We as regulators will continue to streamline our policies to the benefit the people so that no consumer can be mislead by any manufacturer or marketer,” maintains Ashish Bahuguna, Chairman, Food Safety and Standards Authority of India.

Adding to this, Dr Khandelwal shares, “All depends on effective enforcement. Manufacturers/ retailers at all levels should comply and honestly meet the norms, since the FSSAI plans to get local flour mills to add premixed nutrients. Our PDS should be strengthened and made corruption free. Awareness generation campaigns to encourage people to adopt a diversified and wholesome diet should be run simultaneously. Junk food advertising should be curtailed. Also, the issue of affordability should be placed as a central concern, because unaffordable fortified food would defeat the very purpose of fortification.”

At the end, malnutrition cannot be eliminated in a country like India without a political will as well as concerted efforts of all stakeholders. Strategies to resolve the issue of malnutrition needs to be designed keeping in mind that food security and access to healthcare needs to be a basic human right.

raelene.kambli@expressindia.com