India accounts for more than 3 out of every 10 stunted children in the world, and the largest number of babies born with low birth weight per year.In this post, Shweta Khandelwal contends that India has not been able to make strides in its fight against malnutrition primarily because it considers nutrition a problem of food alone, and explains why this thinking is flawed.
Aspirations to contribute as a leader in the world’s economy will need profound attention to the health and nutritional status of our masses especially in their early life, often referred to as the 1,000-day period (nine months of gestation plus two years postpartum).
Shedding light on some of the recent statistics on public health and nutrition (PHN) –90%of the developing world’s chronically undernourished (stunted) children live in Asia and Africa. India alone accounts for more than 3 out of every 10 stunted children in the world. Also, the largest number of babies with low birth weight per year (about 7.4 million)are born in India. Of the ones who manage to survive this disadvantaged birth to begin with, to make matters worse, only 25% of Indian newborns are placed to the breast within one hour of birth. While WHO (World Health Organization) and all other UN (United Nations) bodies advocate for exclusive breastfeeding until six months of age, less than half of children (46%) receive that in India.
Chronic or non-communicable diseases (NCDs),such as,cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes are not only rapidly rising;they are a major cause of premature deaths and lost productivity in India. Although morbidity and mortality from NCDs mainly occur in adulthood, exposure to risk factors (poor diet, low physical activity, tobacco, alcohol consumption) begins in early life. David Barker’s group from University of Southampton was the first to demonstrate linkages between poor nutrition during first 1,000 days and early onset of NCDs in adult life (Krishnaveni and Srinivasan 2019, Krishnaveni and Yajnik 2017, Fall and Kumaran 2019). This was later confirmed in many cohorts across the developing countries including India (Sinha et al. 2017, Fall 2013).
Young environment activist Greta Thunberg said, “Act as if your house was on fire”. We implore you to exercise this urgency for public health and nutrition too. Many of you will find this overwhelming because the fire (damage) is undetected, subtle or even invisible to many,resources to fight it are limited, and understanding on how to douse the fire (strategies for prevention/management) is not straightforward.
Food alone will not solve the problem of malnutrition
Poshan Abhiyaan was launched by Prime Minister Modi in 2018 to help unify and consolidate action on tackling malnutrition using multi-sectoral approach. While this initiative’s vision is lauded, it may be fraught with several operational challenges which could limit its outreach and success. In order to successfully realise the objectives of Poshan Abhiyaan for each and every citizen of our country, it is important that it gains visibility and acknowledgment from all cross-cutting sectors. We have not been able to make strides in our fight against malnutrition primarily because we considernutrition as a ‘food-alone’ problem. Why this thinking process is flawed is because of the following 6Cs:
- Convergence and coherent action are key pieces:According to the World Economic Forum, India needs approximately 230 million tonnes of food per year to feed its population – and India's foodgrain output in 2016-2017 was a record 273.3 million tonnes. So even if we are self-sufficient in grain production, why are our people malnourished? Grain production sits in agriculture ministry (there are no joint platforms addressing this between Ministry of Women and Child Development, Ministry of Health and Family welfare, and Ministry of Agriculture and Farmers’ welfare). What is missing from the nutrition lens is ensuring diet diversity and micronutrient content being available for bio-absorption. We all have seen that undernutrition is substantially higher in rural than in urban areas. Short birth intervals are associated with higher levels of undernutrition. Early marriage fuels malnutrition. The percentage of children who are severely underweight is almost five times higher among children whose mothers have no education than among those whose mothers have 12 or more years of schooling. Thus, other sectors like equity, environment, education, and WASH (water, sanitation, and hygiene) have important roles in contributing to real progress in PHN. We need to package nutrition strongly but smoothly with joint accountability/ownership as relevant. Appraisals of key officers should be carried out based on progress made on these joint fronts.
- Communication plays a key role: At all levels, simpler, more effective and impactful communication strategies prove far more useful at community level. While it is critical to invest in high quality research, it is equally significant to invest in effective communication, synthesis, and dissemination of findings. Integrated curricula drawing upon several sectors must be designed and introduced from early ages. Suitable, local interventions for sustainable, safe, diverse, and balanced meals must be tested. Some clear thoughts on how the collected data by various stakeholders could be collated, and used should be summarised in the form of data use policy. Common platforms to present inter-sectoral findings to key stakeholders (government, schools, workplaces, hospitals, prisons, civil society participation) must be built. Catalyse documentation to action using social advocacy tools for thoughtful conceptualisation, celebrity endorsements, technology, and dedicated resources.
- Capacity building: Several stakeholders like women leaders, youth ambassadors, nutrition champions, school health monitors, wellness coordinators, front-line workers,etc. should be nurtured and empowered further to deliver simple harmonised messages on nutrition and health across multiple platforms. Jan Andolan (people’s movement) will be incomplete and ineffective if the capacity of stakeholders to deliver and/or receive correct message is not strengthened.
- Complement existing policies rather than new proposals each time:it is easy to enumerate multiple programmes and a wide portfolio of initiatives on PHN in India. However, how many of them are synced with each other to deliver impactful results, is something which can be substantially improved in our country. Evidence to policy route needs to be strengthened. Financial levers should be in sync with agricultural policies, women empowerment policies, school health initiatives, food trade laws, etc. For example,exporting/importing palm oil should not be viewed only from profit lens but health implications must be studied as well.
- Conflict of interest and corruption are dampeners to progress:They need to be stringently checked in favour of public health and nutrition. The private sector pumps in a huge amount of money in advertising and driving sales for unhealthy, high fat, sugar, and salty foods. This really clouds the judgement of time constrained caregivers, who often make unhealthy choices due to limited resources (money, time, and knowledge). Also reports of usage of sub-optimal quality food products, leakages, and corruption in some government schemes surface every now and then. These should be addressed via robust, timely monitoring, and expedited action.
- Commitment from womb to tomb for coexisting maladies: Nutrition needs to be supported across the life-cycle. We often see programmes/policies in the PHN space that use a piecemeal approach,which unfortunately end up in divided political, financial, and operational commitments. Time is here to expand horizons and secure sustained flow of resources to tackle multiple forms of malnutrition (undernutrition, overweight-obesity, micronutrient deficiencies) existing in our country. The whole spectrum of infectious diseases to non-communicable diseases needs to be addressed holistically. The first 1,000 days are definitely important but actions to prioritise nutrition throughout the life-course will go even further in ensuring the optimal potential and productivity of our human capital.
Author’s views are personal.
- Fall, Caroline HD and Kalyanaraman Kumaran (2019), “Metabolic programming in early life in humans”, Philosophical transactions of the Royal Society of London, Series B, Biological sciences, 374(1770). Available here.
- Fall, Caroline HD (2013), “Fetal programming and the risk of noncommunicable disease”, Indian Journal of Pediatrics, 80(1):S13-S20. Available here.
- Krishnaveni, Ghattu V and Krishnamachari Srinivasan (2019), “Maternal Nutrition and Offspring Stress Response—Implications for Future Development of Non-Communicable Disease: A Perspective from India”, Front Psychiatry, 10: 795. Available here.
- Krishnaveni, Ghattu V and CS Yajnik (2017), “Developmental origins of diabetes—an Indian perspective”, European Journal of Clinical Nutrition volume, 71:865-869,
- Sinha, S, AR Aggarwal, C Osmond, CHD Fall, SK Bhargava and HS Sachdev (2017), “Intergenerational Change in Anthropometric Indices and Their Predictors Among Children in New Delhi Birth Cohort”, Indian pediatrics, 54(3):185-192. Available here.