Raising the diet of our people from subsistence level to higher levels of nourishment by overcoming the triple deficit is the only way to improve the nutritional indicators of our population — amongst children, adolescents and adults.
It is nearly a month since the first phase of the NFHS-5 survey was published. While we await a response from the government or any policy-making authority, several articles by public health/policy experts have appeared, expressing deep concern at the deteriorating nutrition and anaemia indicators, especially among children.
More deterioration in nutrition indicators following the COVID-19 pandemic is feared in the next phase of NFHS-5, primarily on account of loss of livelihoods, reduced food consumption among the poor and disruption of government nutrition programmes.
Most articles emphasise the need for higher budgetary allocations for healthcare, ICDS and monitoring systems. While these are no doubt necessary, a debate must also be initiated on whether the current programmes are adequate and effectively target the root causes of malnutrition or if the strategies require change.
The political executive and policymakers must also note that unlike a disease outbreak, which leads to an immediate public demand for government intervention, there may not be any popular demand to address malnutrition — the public, by and large, does not have adequate information about their affliction.
All they know is that they are poor, get tired easily, and their children fall ill often. Hence, in the Indian context, it becomes the responsibility of the government/civil society to first provide information and awareness to the community about malnutrition and its causes, and then implement programmes to address them.
The government could start showing its seriousness by examining the current nutrition-related programmes, and analysing why they are not able to reduce malnutrition faster. Do they require complete overhaul? Should additional interventions be introduced in pockets, identified as high-burden districts? Surely, there should be different norms and more intensive interventions within the ICDS for these chronically malnourished pockets with the poorest indicators.
How does the government plan to address adolescent malnutrition (our future demographic dividend) which is as alarming as child malnutrition, and for which we have no clear strategy in place yet? And, finally, we need to know if the National Nutrition Policy 1993 is still operational.
If it is, then there is an urgent need to update it, and prioritise interventions in accordance with the latest surveys and research findings. If not, it seems that we are attempting to address this invisible scourge without a policy framework or plan of action.
The discussion should also include another vital question: Do the current interventions address the root causes of malnutrition in India? I refer to them as the three deficits. The first is the large dietary deficit among at least 40 per cent of our population of all age groups, brought out repeatedly in a succession of reports this decade — the National Nutrition Monitoring Bureau’s Third Repeat Survey (2012), NFHS 4, 2015-16, the NNMB Technical Report Number 27, 2017. Clearly, our current interventions are not being able to bridge this protein-calorie-micronutrient deficit.
The NHHS-4 and NFHS-5 surveys reveal an acute dietary deficit among infants below two years, and considerable stunting and wasting of infants below six months (caused by foetal malnutrition/maternal dietary deficit). Unless this maternal/infant dietary deficit is addressed, we will not see rapid improvement in our nutritional indicators. This is a serious problem which needs to be acknowledged and prioritised in the public health/public policy agendas.
The next is the even bigger information deficit at the household level, especially among lower-income families. We do not have a national IEC (information, education and communication) programme that reaches targeted households to bring about the required behavioural change regarding some basic but critical facts — for example, about the importance of balanced diets in low-income household budgets, proper maternal, child and adolescent nutrition and healthcare. IEC and behavioural change have been highlighted in all our early Five-Year Plans, but somehow, successive governments have not been able to make it happen.
The largest deficit, which is a major cause of dietary deficiency and India’s chronic malnutrition, pertains to inequitable market conditions that deny affordable and energy-fortified food to children, adolescents and adults in lower-income families. The market has stacks of expensive fortified energy food and beverages for higher income groups, but nothing affordable for low-income groups except non-nutritive junk that cost about Rs 5.
It is perfectly possible to produce nutritive fortified energy food for children within Rs 5 from wheat, defatted soya, green gram, and ragi malt, providing around 380 calories from 25 grams. A feasibility study conducted by KPMG in 2018 under the Karnataka Multi-sectoral Nutrition Pilot Project reckons that there is a market demand of 42 million tonnes of low-cost energy food per year, but strangely, no private entrepreneur wants to enter this field. One wonders why, in spite of the mandate of the National Nutrition Policy 1983 and the National Plan of Action on Nutrition 1995. The feasibility study also has firm findings about a direct correlation between the high incidence of underweight, stunting and wasting among children, low body mass index and stunting among adolescents, and the lack of low-cost fortified energy food in the market.
Raising the diet of our people from subsistence level to higher levels of nourishment by overcoming the triple deficit is the only way to improve the nutritional indicators of our population — amongst children, adolescents and adults. We expect the government to show its seriousness and start addressing this issue urgently through new ideas and innovations.