Malnutrition

Despite decades of efforts to fight this malaise, India’s nutrition profile is still one of the most alarming in the world. The Global Hunger Index (2020) placed India precariously at the 94th spot among 107 countries. This has once again underscored the brewing malnutrition crisis in India. The reasons behind this crisis have often been attributed to historical antecedents such as poverty, inequality, and food shortage. However, countries that are similarly placed with us, have fared far better in this regard. Developing countries such as Sri Lanka, Nepal, Bangladesh, Myanmar, and Pakistan have been ranked higher than India on the Global Hunger Index. Before dwelling on what has brewed this crisis in India, let us first understand the basics of malnutrition.

What is Malnutrition?

World Health organisation defines Malnutrition as “deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.” It is a health condition that arises when the human body is deprived or is over-supplied with vitamins, minerals, or other micronutrients that are essential to keep the body and its tissues healthy. It develops either in undernourished or over-nourished people.

Types of Malnutrition

Broadly speaking, malnutrition can be categorised into two types:

Undernutrition

It is a condition when not adequate nutrients are consumed by the body or when they are being excreted more rapidly than they are being consumed. In simple words, it arises when the body is deprived of basic energy to sustain itself. To keep the system going, our body compensates for the energy deficit by preying upon its own tissues, leaving them malfunctioning and weak.

Symptoms:

• Low body weight and reduced muscles
• Stunted physical and mental growth
• Weakness, fatigue
• Compromised immunity and thereby frequent infections and diseases
• Low heart rate and blood pressure

It is usually measured using indicators like wasting(weight-for-height), stunting (height-for-age), underweight(weight-for-age), and deficiencies in vitamins and minerals.

Overnutrition

WHO has recently added overnutrition to the expanded definition of malnutrition, recognising its detrimental effects in equal magnitude to that of its counterpart. It arises due to an over-supply of nutrients in the body, resulting in the accumulation of body fat that impacts the health of the individual. When excess nutrients are consumed, the body stores them as fat cells in adipose tissue. But when the tissues run short of space, fat cells cause chronic inflammation inviting a host of metabolic disorders.

Symptoms:

• Obesity
• Over-weight
• Non-communicable diseases that arise due to dietary habits, like cardiovascular diseases and hyper tension, etc.
• Toxicity arising out of overdosage of nutrients
• High blood pressure.
• Insulin resistance.

Overnutrition is measured using Body mass index and other physical measurements like waist circumference, waist to hip ratio, etc.

Who are at risk?

Certain sections of population are more prone to malnutrition. A few of them are;

Undernutrition

1. Low-income communities: By virtue of lacking financial resources deprives them of requisite nutrition intake.
2. Children: Children need more nutrition than the adults due to developmental needs of the body.
3. Chronically ill: Chronic diseases often effect the absorption of the food and appetite. This results in under nutrition as body starves of nutrition.
4. Elderly: With age, elderly people often suffer from lack of appetite, poor absorption of food, compromised immunity that results in frequent diseases, etc.

Overnutrition

1. Affluent communities
2. People with sedentary life styles
3. Genetically predisposed people

Malnutrition: A Global Problem

Malnutrition is a global public health crisis that occurs in both children and adults. It is not only a health concern but it has an all-pervading effect on many spheres like poverty eradication, productivity and economic growth. It is affecting people regardless of country, ethnicity, gender, and geographical regions.

• There were 79.5 crores undernourished people in the world in 2014.
• 1.9 billion adults are either obese or overweight, while 46.2 crores are underweight.
• Globally in 2020, 14.9 crores of children under five were stunted (too short for age), 4.5 crores were wasted (too thin for height), and 3.89 crores were overweight or obese.
• Around 45% of deaths among children under five years of age are associated with undernutrition.

The major burden of malnutrition is shouldered by regions like south Asia, sub-Sahara, Caribbean and west Asia.

India’s Malnutrition Profile

India is one of the worst performers in terms of malnutrition in the world. It was corroborated by the first National Family Health Survey (NFHS) conducted in 1992-1993. However, since then, the malnutrition profile of India hasn’t made any significant progress.

• As per the UN report, there are about 22.43 crores of undernourished people in India (2019-21), among which women and children constitute the majority.
• As per official figures from 2015-16, 22.9% of the women belonging to the age group of 15-29, are found to be underweight, whereas their male counterparts fare a little better with 20.2% of them being underweight.
• According to the State of Food Security and Nutrition in the World-2020 report, almost 51.4% of Indian women in reproductive age are found to be suffering from anaemia. And almost half of the women are suffering from undernutrition and anaemia.
• About 6 crores of children in India are under weight, about 36.1 are stunted and 21% are wasted. Adding to this, 57% are suffering from deficit in Vitamin A and 75% are anaemic.
• Recently, the central government in Rajya Sabha has acknowledged that a total of 9,27,606 children in India are acutely malnourished.
• Approximately 70.5 percent of the population were unable to afford a nutritious meal in 2020.
• Official data from the National Family Health Survey-5 reports that 24% of the men and 23% of the women in India are obese now.
• Same survey reports that 21% of the women and 25% of the men above 15 years are suffering from hypertension, which could be a result of Overnutrition.

States like Assam, Bihar, Uttar Pradesh have the highest prevalence of malnutrition in India, whereas states like Meghalaya, Maharashtra, Gujarat fare worse in terms of child malnutrition.

Reasons Behind

Under nutrition

1. Poverty: Over the course of the last twenty years, foodgrain production in India has leaped from 198 million tonnes to 269 million tonnes. Yet India ranks dismally low on the Global hunger Index in 2021 i.e., 94/107. Though India has achieved a significant level of food security, still a large chunk of the population goes to bed every night with a hungry stomach. The lack of sufficient income deprives BPL people of requisite nutrients and timely medical care. Poor families not only are unable to afford quality food, but they also couldn’t afford proper hygiene and sanitised living conditions. As a result, they are vulnerable to various infections, which in turn impact their body’s absorption capacity of food. Adding to their woes, their inability to afford timely medical intervention further worsens their plight.
2. Imbalanced diet: The majority of the population in India isn’t aware of healthy dietary habits. As a result, we often end up consuming an imbalanced diet that is dominated by carbohydrates. Unfortunately, our staple food i.e., rice & wheat, is loaded with heavy carbs and little proteins. As a result, protein intake is grossly ignored or undermined.

As per the Indian Council of Medical Research (ICMR, an average person should consume 0.8-1 gm of protein per kg of body weight each day. However, ICMR reports that an average Indian doesn’t consume more than 0.6gm per Kg of body weight, thereby falling short of consuming the daily required threshold.  The per capita consumption of pulses is merely 50% of the recommended intake. A typical Indian diet is constituted of 50% of grains and tubers, just 9% of meat/pulses, and 17% of dairy. A survey conducted by National Nutrition Monitoring Board (NNMB) shows that Indians derive about 60% of their protein from cereals which have relatively poor digestibility and lack essential amino acids.

3. Maternal health: Maternal health plays a significant role in a baby’s health, especially during the pregnancy and breast-feeding phase. But almost 51.4% of the women of reproductive age in India are found to be suffering from anaemia. Diets lacking in key nutrients like iodine, iron, folate, calcium and zinc are found to be causing anaemia, pre-eclampsia, haemorrhage and death in mothers. They lead to stillbirth, low birth weight, wasting and developmental delays for children.
4. Gender disparity: As the statistics suggest, women are more vulnerable to malnutrition in India than their male counterparts. This isn’t surprising in a patriarchal society like ours where women’s needs are often ignored, downplayed, or subdued under men’s needs. The customary habit of Indian wives eating only the left-overs has taken a toll on their nutritional profile. Moreover, the practice of marrying the women underage, and thereby pregnancy at earlier ages leave them undernourished.
5. Poor sanitation: Lack of sanitation in drinking water and consumed food leads to several kinds of gut infections, which prevent the intestines from absorbing the food, leading to compromised nutrition. Poor sanitation is associated with the spread of diarrhoeal diseases such as cholera and dysentery, and other diseases like typhoid, intestinal worm infections, and polio. It results in stunting and contributes to the transmission of antimicrobial resistance.
6. Food inflation: A balanced diet is still unaffordable for low-income communities. India, in the recent past, is witnessing a worrying trend in food inflation as it crossed 8% in the current fiscal year.
7. Inadequate budgeting: Unfortunately, malnutrition hasn’t attracted the attention of budgeting think-tank in India. The Union government has just allocated 0.57% of its budget to child nutrition. The total budget for 2021-22 has grown by 14.5%, but the allocation to nutrition has dropped by 18.5%. CAG audit in 2020 has remarked that out of a total outlay of 1,042 crores allocated to ICDS, only 908 crores were actually disbursed to state governments. Similarly, only 1,570 crores out of the total allocation of 4,300 crores for POSHAN Abhiyan were spent.
8. Lax administration: ICDS, NFSA and midday meals were riddled with corruption and administrative gaps right from the beginning. Acute Encephalitis Syndrome (AES)outbreak in Bihar spotlights the failure of the Integrated Child Development Scheme (ICDS) in the state.

Overnutrition

1. Increasing incomes: Actually, increasing incomes alone couldn’t be the culprit. When income increases without any parallel increase in dietary awareness, it would lead to overnutrition. Lack of awareness is resulting in overconsumption of unhealthy diets that are rich in carbs and fats.
2. Junk food culture: People are increasingly availing the readymade food, that is accessible at their door step. Restaurant foods are heavy in fats, leading to obesity in consumers. Increasing employment of women, who were otherwise homemakers, is resulting in more people opting for online or restaurant food.
3. Sedentary lifestyles: Increasing white collar jobs and transportation facilities has drastically reduced the calorie expenditure of people, ultimately resulting in increased weight gain.

Pandemic: A catalyst

The pandemic has disturbed the nutrition profile across the globe. The worst ripples were borne by low and middle-income countries like India. Children and women bore most of the brunt. Some of the strategies to tackle covid-19 like the closure of schools, lockdown, and trade restrictions have disrupted the food supply chains thereby choking the availability, access, and utilisation of nutrition resources.

• The nationwide lockdown has displaced millions of employees from workplaces. Millions of others have become unemployed over the course of the lockdown. As per International Labour Organisation (ILO) and the Asian Development Bank (ADB), nearly 4.1 million Indians have lost their jobs during the pandemic. This has drastically reduced the purchasing power of millions of families. People had to cope with reduced or cessation of incomes through reduced purchasing of food, substituting wholesome food with less nutritious alternatives.
• The disruption in food supply chains has diminished pregnant women’s food and nutrition consumption drastically. Shortage in supply of fruits, vegetables, eggs, meat, fish, etc, has compromised the nutrition intake by the pregnant women and the off-springs during this period.
• COVID-19 has also significantly disrupted the network of government-run health and nutrition initiatives like ICDS, NFSA, Mid-day meals, etc. A disruption in these services have deprived many children and pregnant women of vital nutrition intake.

The pandemic cast a serious challenge to the already vulnerable & fragile nutrition security of India. Women and children are expected to continue to bear the disproportionate weight of the pandemic-exacerbated nutrition crisis in coming years as well.

Consequences of Malnutrition

Health Impacts

1. Vulnerability to diseases: Lack of adequate nutrients in the body compromises the body’s immunity system, thereby leaving the body vulnerable to multitude of infections and diseases like diarrhoea, typhoid, measles, malaria, etc.
2. Developmental delays: The worst consequences of malnutrition are manifested during the pregnancy and the first 1000 days of the child. Children, who are undernourished in the womb, are prone to develop immunity disorders and thus are more susceptible to infections and diseases. Stunting in children delays the development of motor and cognitive abilities of the children and these are largely irreversible.
3. Poor maternity health: Under-nourished pregnant women are at a greater risk of passing down their malnutrition to their offsprings, which manifests in various developmental disorders in the offspring.

Education

Delayed or compromised cognitive abilities derail the education of children. As per the studies of UNICEF, stunting in early life is attributed to 0.7-grade loss in schooling, a seven-month delay in starting school education, and between 22% and 45% reduction in lifetime earnings. Stunted children become less educated as adults, compared to their peers, thus making malnutrition a long-term issue.

Economic

1. Diminished productivity: Stunted and wasted adults are less likely to work at their full potential. Malnutrition diminishes the mental and physical abilities of the person and consequently, their productivity is often compromised. As per the World bank report 2006, it is estimated that a 1 % reduction in adult height due to childhood stunting results in a 1.4% loss in productivity of the individual. Thus, malnutrition lands an individual in a vicious cycle of poverty.
2. Dent to the economy: Malnourishment during childhood would leave individuals prone to many diseases in the later stages like non-communicable diseases, diabetes, etc; swelling the health care costs in already resource-crunched developing countries like ours. As per the world bank, the economic cost of malnutrition is reckoned to be in the range of 2 to 3% of Gross Domestic Product, to as high as 16 % in most affected countries.

Existing policies: How we are tackling the evil

• Integrated Child Development Services: It was initiated in 1975 and was touted to be the first major attempt to fight malnutrition in India. It was taken up by the Ministry of women and child development. It was aimed at providing food, pre-school education, immunization, primary healthcare, primary health check-up and referral services to children under 6 years of age and their mothers.
• Pradhan Mantri Matru Vandana Yojana (PMMVY): This scheme was launched in 2017 with an aim to transfer 6,000directly to the bank accounts of pregnant women and lactating mothers to compensate for the loss of wage and to be able to afford nutritious food during the period.
• Mid-day meal scheme: One of the most ambitious schemes aimed at providing nutritious food for the children between 1-8^th class at all government schools and government funded schools.
• National food security act 2013: It aims to ensure food and nutrition security for the most deprived sections at affordable prices. It lays special emphasis on kids and pregnant & lactating women.
• National nutrition mission: Its aims are;
• Reduce stunting and wasting by 2% per year (total 6 per cent until 2022) among children
• Reduce anaemia by 3% per year (total 9 per cent until 2022) among children, adolescent girls and pregnant women and lactating mothers.
• FSSAI’s guidelines: To fortify staple grains namely Wheat Flour and Rice with Iron, Vitamin B12 and Folic Acid; Milk and Edible Oil with Vitamins A and D and Double Fortified Salt (with Iodine and Iron) to tackle micronutrient malnutrition in India.
• Poshan Abhiyaan: This is the latest of the efforts and has replaced the mid-day meal scheme with scores of provisions, some of which include;
• Coverage: Primary (1-5) and upper primary (6-8) schoolchildren. It aims to benefit about 11.80 crores of children studying in 11.20 lakh schools in the country. They are entitled to a meal of about 700 calories.
• Nutritional garden: It will promote the development of nutrition gardens in the school backyards, which will ultimately be used to provide additional micronutrients to the students.
• Supplementary Nutrition: Districts with high prevalence of anaemia can compliment with additional supplements like local vegetables, fruits, etc.
• Nutrition Expert: A nutrition expert is to be appointed for each school, whose is responsible for conducting regular check-ups such as Body Mass Index (BMI), weight, haemoglobin levels, etc.

Way Forward

As the crisis is spreading like a wild fire under the carpet, the government cannot afford any further laxity. The following measures would go a long way in tackling the hidden evil.

• Ensure synergy between various ministries like Ministry of women and child welfare; Ministry of Health, Ministry of tribal affairs; Public Distribution and Civil Supplies; Drinking Water and Sanitation.
• Improve data collection as India bags the notoriety for poor and erroneous data collection. India should train requisite human resources to collect the factual data so as to facilitate appropriate policy formulation.
• Increased budgetary allocation to social welfare programs.
• Make welfare schemes more accountable and fool-proof through conducting periodic social audits.
• Assign a bigger role to panchayats in implementation of nutrition schemes
• Diversify the food basket of public distribution scheme.
• Special emphasis on adolescent girls as they are key to achieving nutrition security.
• Improve access to public healthcare for poorer communities
• Leverage the services of civil society.
• Learn from the global best practices. One such example is the Brazil’s “Fome zero program”. It was launched by the Brazil’s government in 2003 with the goal to achieve food and nutritional security among the people. It has met huge success due to an effective implementation a strong political will by the government.

As M.S. Swaminathan acclaimed, now it’s time for India to shift its focus to achieving nutritional security as we have made enough progress in terms of achieving food security. As a nation that aspires to be a global superpower in the coming decades, we can no longer afford our human resources to be crippled by malnutrition. Only if our population is healthy, we can unleash the full potential of our demographic dividend and tread towards our global ambitions.

References

• Time to get serious about nutrition security – The Hindu BusinessLine
• Child malnutrition in India: A systemic failure (downtoearth.org.in)
• India: How COVID-19 Accelerates Malnutrition in Women and Children – India | ReliefWeb
• The social and economic consequences of malnutrition (europa.eu)

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