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The Undernutrition Conundrum in India: Current Scenario and Way Forward

K K Asha, Suseela Mathew and M M Prasad

Abstract
In India, nutrient deficient diets are a fact of everyday life for millions. The most worrying aspect which should concern us greatly is that the largest undernourished population in the world call India their home. Several factors are accountable for the current serious levels of malnutrition seen in the country some of which are- woefully inadequate maternal nutritional status, unpredictable lactation behaviour, inappropriate infant and young children feeding practices, lack of women's education, and scant regard for sanitation. High levels of child malnutrition potentially result in poor physical growth, recurrent childhood illnesses that further impede development, low cognitive skills and educational attainment and diminished productivity in adult years impeding socio-economic development of the country. Though several government programs are in place, there remains a need for effective use of nutritional data generated and knowledge gained across studies to address multifaceted problem of undernutrition. The current grave circumstances of undernutrition in India emphasizes on the urgent necessity to take appropriate actions to improve the nutrition of its people so as to enable India to meet its Sustainable Development Goals of Agenda 2030.

Malnutrition in India
World Health Organization (WHO) defines malnutrition as a condition arising from deficient, excessive or imbalanced intake of nutrients/and or energy (Blossner and de Onis, 2005). Optimum growth and overall development of an individual including his or her socio-economic ranking is an outcome of interplay of maternal, infant and childhood nutrition. The presence of malnutrition is ascertained based on three simple tests, namely; anthropometric measurements, biochemical indices and clinical tests of which anthropometric measurements facilitate rapid evaluation of nutritional state of a person due to its ease of use on a large scale (Casadei and Kiel, 2020). While malnutrition in adults is assessed by body mass index measurements, in children under-5, the three WHO standards of nutritional indices, weight for age, height for age and weight for height are used (de Onis and Blossner, 2003).

The FAO estimates that in 2018, about 196 million people in India or almost 15% of its population is undernourished (FAO, IFAD, UNICEF, WFP and WHO. 2018).  India finds itself at 102nd place among 117 qualifying countries in the 2019 Global Hunger Index suffering from a level of hunger that is serious as indicated by its GHI score of 30.3. The GHI score is based on four indicators: under-nourishment, child stunting, child wasting, and child mortality.

Stunting, wasting and being underweight
Stunting, or low height for age, is caused by insufficient intake of nutrients over a long time. Also, chronic low nutrition causes and exacerbates frequent infections which is also a cause for stunting. Stunting commonly manifests before the age of two, and its effects are mostly irreversible. These include delayed motor development, impaired cognitive function and mediocre performance at school. Almost one third of children under five in the developing world are stunted. Wasting, or low weight for height, is when a child is thin for his or her height but not essentially short. Wasting is a strong predictor of mortality among children under five and wasted children carry an immediate increased risk of morbidity and mortality (UNICEF, WHO & WBG, 2018). It is usually caused by acute shortage of food and worsened by recurring disease. It is quite unfortunate that India reels under the burden of undernutrition among its children who are under-five. About 38 per cent of the children under five are affected by stunting (WHO, 2018) and 21 per cent of children under 5 have been defined as ‘wasted’ or ‘severely wasted’ – which means that they weigh dismally less for their height. Moreover, 51 per cent of the women of reproductive age suffer from anemia who bear children that are anemic by birth. The proportion of underweight children under 5 declined from 52% in 1990 to 33% by 2015, (Nie et al, 2019) but is still far from the target of reducing it by half. On the other hand, the fast-paced growth in the country’s economy has also resulted in the emergence of overnutrition associated with chronic diseases and premature death.

World Health Organization’s six global nutrition targets
Recognizing the need for augmented global action to address the widespread and debilitating challenge of the double burden of malnutrition, the World Health Organization in 2012 endorsed an all-inclusive implementation plan that focussed on improving maternal, infant and young child nutrition. The plan detailed a series of six global nutrition targets that had to be met by 2025: (1) reduce the number of stunted children under 5 by 40%; (2) reduce anaemia among women of reproductive age by 50%; (3) reduce low birth weight by 30%; (4) 0% increase in childhood obesity; (5) up to at least 50% increase in exclusive breastfeeding rate in the first 6 months; (6) reduce childhood wasting to less than 5%. According to Global Nutrition Report (GNR) 2018 India has shown improvement in reducing child stunting, but is not on track to achieve any of the WHO’s six nutrition goals by 2025 (DIPR, 2018). This is essentially because India is home to 46.6 million stunted children, 30.9% of all stunted children under five- the highest in the world.

The United Nations’ 17 Sustainable Development Goals
On September 25, 2015, building up on the Millennium Development Goals, a new sustainable development agenda, defined by 17 global Sustainable Development Goals (SDGs) to end poverty, protect the planet and ensure prosperity for all was adopted by 193-member states of the UN General Assembly (Morton et al, 2017). The SDGs are a series of comprehensive targets committed by world leaders to achieve social, environmental and economic welfare of societies by the year 2030. The 17 SDGs present a major political challenge in terms of scope and scale. While several countries including India have made some progress, the pace of action is still far too slow and what could be achieved by 2030 is far too little than what is envisaged. The core difficulties that are associated with each SDG have become progressively complex, and necessitate action at all levels – from household to community to nation – and through several sectors.

India's overall score for the SDGs is 58 with a score of 48 for SDG 2 on Zero Hunger. The NITI Aayog and the United Nations' report - 'SDG India Index - Baseline Report 2018' tracks the progress the states and UTs of India have made towards achieving the SDGs. The numbers of the undernourished in India have significantly reduced over the past two decades, but India still carries 23.8% of the global burden of malnourishment. Though several government programs are in place, there remains a need for effective use of nutritional data generated and knowledge gained across studies to address multifaceted problem of undernutrition. The current grave circumstances of undernutrition in India emphasizes on the urgent necessity to take appropriate actions to improve the nutrition of its people so as to enable India to meet its Sustainable Development Goals of Agenda 2030.

The distinctive case of Indian undernutrition: causes and way forward
One of the world’s largest flagship nutrition programs Integrated Child Development Services (ICDS) focusing on nutrition for children under-5 was instituted in India in the year 1975 (Lokshin et al, 2005). It is quite ironical and a matter of deep concern that almost 5 decades down the line we are still languishing in the lower rungs of international rankings on child nutrition indicators.

India having realized the importance of optimum nutrition for its people to build a strong nation, has formulated several legislative policies and programs over the years. National programs addressing direct causes as well as the fundamental determinants of undernutrition have been designed and implemented in a manner such that positive nutrition outcomes are attained through nutrition responsive and nutrition specific interventions. Despite these efforts, India is reeling under the pressure of high levels of undernutrition.

Some of the notable policies and programs in place in India are briefly listed here

  • The Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003 -to provide a strong policy framework for protecting, supporting and promoting nutrition interventions – particularly during stages of highest susceptibility for children and women.
  • The National Nutrition Policy 1993, supported a multi-sectoral strategy for eradicating malnutrition and achieving optimum nutrition for all.
  • The National Health Policy 2002, aimed at decentralizing public health and ensuring an equitable access to health service across India
  • The National Food Security Act 2013 mandates food and nutrition privileges for children, pregnant and breastfeeding mothers
  • The National Policy for Children, 2013 provides a strong basis for focusing on the immediate and the fundamental determinants of undernutrition through both direct short-term interventions and long-term indirect interventions.
  • The Twelfth Five Year Plan reinforces the assurance to prevent and reduce child undernutrition, uniting multiple sectors and States to collective action.
  • Some national programmes are Integrated Child Development Services, Matritva Sahyog Yojana, National Health Mission- including RMNCH + A, SABLA for adolescent girls, Janani Suraksha Yojana, Swachh Bharat including Sanitation and the National Rural Drinking Water Programme, Mahatma Gandhi National Rural Employment Guarantee Scheme and the National Rural Livelihood Mission, Mid-Day Meals Scheme, National Food Security Mission, Targeted Public Distribution System.
  • As the current nutritional interventions were deemed insufficient, a national program in Mission mode National Nutrition Mission was launched in 2014 to halt the worsening undernutrition situation in India. Also, with NITI-Aayog being roped in to examine the status of undernutrition and formulate a strategy targeted at the poor/non-performing districts/states, nutrition was brought on to the center stage of the National Development Agenda and it is under this policy context that the National Nutrition Strategy was framed in 2017.

Why is India home to the largest number of malnourished children in the world?
Fundamental causes of undernutrition. Poverty, food security and illiteracy are recognized globally as three of the most important causative factors for malnutrition (Hannum et al, 2014). Low levels of education among girls make them more likely to be undernourished, who grow on to become undernourished mothers who invariably give birth to low birth weight babies. Maternal illiteracy has also been associated with low socio-economic status and poor feeding practices (Katiyar, 2016). India has a grave distinction of having one of the world’s largest female illiteracies, making progress in improving maternal and child nutrition outcomes painfully slow.

Intergenerational concern. It is important that we confront malnutrition from an inter-generational perspective. One of the crucial factors affecting the growth and development of future generations is the quality of maternal nutrition. It is quite commonplace in India to find pregnancies among malnourished anemic adolescent girls (Toteja, 2006) who have to further cope with the problem of insufficient spacing between consecutive births, poor nutrition and dismal postnatal healthcare. Children born to these mothers grow up to be stunted and grossly underweight adolescents having been fed poorly and raised in unhygienic conditions with no healthcare provisions. Also, when a child’s intake of essential macronutrients and micronutrients is significantly insufficient, her susceptibility to disease is aggravated further impeding her growth. This cycle is repeated over and again across generations resulting in cohorts of malnourished populations. In addition to adequate nutrition, other determinants that operate at household level are critically important to address malnutrition, these factors being shelter, food security, pre and post-natal care, a healthful atmosphere that includes good hygiene and sanitation and safe drinking water and affordable and easily available healthcare. The social, political and economic milieu that a particular household or a person is in will ultimately determine whether these basic rights are easily available and if they are put to effective use.

Role of education. According to the NFHS-4, 2015-16 report, the all India average of stunting among children under 5 years of age is 38.4% (IIPS and ICF, 2017). Eight states have levels of stunting exceeding the national average while 14 states have stunting rates less than 30%. To understand the role education levels play in improving nutritional status among people, it might be appropriate to compare two Indian states, Uttar Pradesh and Tamil Nadu. UP, with stunting percentage of 46.3 has one of the highest stunting rates in the country while TN is at the lower end of the stunting scale at 27.1%. Both the states receive the same amount of annual rainfall and the prevalence of anemia among women of both states is comparable, but the higher female literacy levels in TN (73.86 in TN and. 59.26 in UP) and better awareness regarding hygiene and sanitation, have contributed to lowered stunting rates in TN. Women in TN also have far better access to ante natal care than their counterparts in UP which positively impacted delivery outcomes, improved infant birth weights,  slashed stunting rates and reduced the prevalence of underweight children below five years of age.

Idiosyncratic traits of the Indian society. Of the many regressive traits that plague the Indian society, the all-pervasive caste and gender-based inequalities are in the forefront which have a significant negative impact on nutritional status of its population. The NFHS-4 Report (IIPS and ICF, 2017) also focusses on the continued disparities in literacy rates and employment among men and women in India. The low levels of women’s education and participation in domestic decision-making and regressive social mindsets have major adverse effects on maternal and child nutrition outcomes. 

Inequitable distribution of resources. Currently, there is a skewed pattern of distribution of resources, both physical and financial among communities and individuals. Certain adverse agro-climatic and geographical features prove to be a hindrance to equitable partaking of the fruits of progress, placing certain populations at a disadvantage (Baker and Grosh, 1994). Malnutrition rates among the tribal population across India have remained exceptionally high and are way above the national average. The NFHS-4 report states 44% of tribal children under five years of age are stunted, 45% are underweight and 27% are wasted (IIPS and ICF, 2017). While it is widely understood that malnutrition stems from several causes that are grouped as direct (insufficient diet and disease), fundamental (food insecurity, deprivation, limited access to health and water, sanitation and hygienic services) and other basic causes (general socio-political and economic milieu), tribal populations are subject to neglect and are plagued with additional concerns. Primarily they are issues like geographical seclusion, cultural disparities, inadequate attention by the state on development processes, inadequate access to public amenities and the like. Additional concerted efforts are needed to help these deprived communities to overcome the challenges and improve their access to nutrition related sectors so that the alarmingly high rates of undernutrition can be checked.  

The race to achieve SDG2. The government has a very important role to play in building a facilitating environment for the overall healthy growth and development of children. This can be achieved by having a singular commitment and by making continued and focused efforts to tackle child and maternal undernutrition in line with SDG2 of zero hunger adopted by the United Nations. By achieving successful nutrition outcomes for its population, India wouldn’t be just achieving SDG2 but it would be making a significant progress in achieving all of the other 16 SDGs, in effect driving a sustainable development as envisaged by the United Nations. In essence, to attain sustainability in development it is imperative that we first make a headway against undernutrition. Conversely, successful achievement of SDG2, heavily depends on how much progress we make across all of the other SDGs like those aimed at clean water and hygiene, sustainable energy, gender equality and education.

It is unaffordable to be oblivious of the importance, improved nutrition holds for India, as it can lay the foundation for calm, protected and steady societies by becoming the key factor for progress in sectors like health, education, women empowerment and gender equality.

Resolving the conundrum of undernutrition: Action Points
The following aspects allow us to repose confidence in the Indian public systems to achieve targets for reducing child and maternal undernutrition: 1) elaborate planning and efforts that have been put in to map the extent of under-5 children and maternal undernutrition (Sahu et al, 2015), 2) strong constitutional, policy, plan and program initiatives taken at the Centre and State level over the past four decades (Banik, 2016),  3) The public service system, in place in India, targeting children under-5, reaches out to children in every village and town in the country and is one of a kind in the world. 4) What is also heartening to know is that the nutritional data pertaining to each and every child under 5 is available at the anganwadi level. And surveys by autonomous bodies like National Family Health survey (NFHS) have generated vast data on multiple dimensions of maternal and child nutrition. NFHS, a series of large-scale surveys conducted in a characteristic sample of households throughout India, under the aegis of the Ministry of Health and Family Welfare, Government of India, the latest of which is the NHFS-4 released in 2015-16 (NFHS), is a multi-round survey. Public service systems should put all the rich data at hand to appropriate and effective use and develop policies and approaches that benefit every mother and child.

1. For effective implementation and follow up of nutrition strategies, information on real time nutritional status of a child should be readily available, which is unfortunately lacking. While NFHS reports are released once in a decade, what essentially is required is a systematic monitoring on a monthly basis of growth pattern of every child from birth to 5 years of age so that attention to their nutrition and health needs is ensured from ICDS as well as public health systems.
2. It is mandatory that information on weight of children under 5 be gathered from each anganwadi and collated at the state level and submitted to the Ministry of Women and Child Development as ICDS Monthly Progress Reports. ICDS MPRs for each state are a record of weight of children, very crucial for successful implementation of policy measures. But these are not sent regularly revealing lack of accountability which is a major hindrance to improving nutrition outcomes in children under 5.
3. There are also reports of wide prevalence of under reporting of undernutrition levels by ICDS machinery across states which may be due to lack of stress on precise growth reporting. With no mechanisms in place to check the authenticity of the data generated by the ICDS functionaries, the reports aren’t reliable for use by policy implementers. 
The key to solving the complex problem of undernutrition is to identify the fact that undernutrition occurs at specific pockets across states in India. Zeroing down on these areas and reaching out to each underweight or stunted or wasted child through proper remedial action will only yield positive outcomes.
4. The government has several Supplementary Nutrition Programs (SNPs), like the provision of cooked meals to children of age 3-6, distribution of take-home rations, supply of nutritious food to pregnant and breastfeeding women etc.  With the annual budget for implementation of these programmes running into a few 1000s of crores of rupees, the role played by middle men and other private parties in siphoning of the funds cannot be ignored and it is imperative that the contractor-politician-bureaucratic link be broken to safe guard public funds. 
5. The fact that up to 60% of women are anemic and that about 23% of women have sub-normal BMI impacts nutritional status of the child adversely and thus paying attention to maternal nutrition is very crucial to improving child nutrition outcomes.
The provision of food grains is assured at vastly subsidized rates to poorer households through legislations like the National Food Security Act, 2013. But for such legislature to be successful in its agenda, streamlining of Public Distribution System in a manner such that promised supplies are received by the households in a time-bound manner is essential.
6. It is vital that nutritional needs of a child in the first thousand days of her life are critically met to ensure her overall mental and physical growth and intellectual development. The care for the child should start as early as the time of its conception by ensuring that the pregnant woman receives optimum levels of nutrition. It has to be ensured that the public health delivery systems and ICDS operating at the sub-district level, villages etc work in close association and record each woman’s pregnancy, provide her with the requisite ante natal care, ensure safe delivery and post-natal care for both the mother and the infant until she/he reaches the age of five.
7. The current percentages of stunting, wasting and underweight prevalent in India have placed the country in a very unenvious situation on the global stage. Amending these numbers needs some concerted efforts by the Government which on its part seems to be on the right track by paying close attention to weight and height figures of a child as a measure of her/his nutritional status.  In districts of high incidence of stunting, wasting and underweight among children under 5, weights and heights can be methodically monitored, promptly initiating remedial measures to improve the nutritional status wherever necessary.
8. Inefficient and often corrupt functioning of the ICDS machinery arises from the fact that there is a phenomenal concentration of power in the hands of a few in the ICDS Directorate. On the contrary, effective tackling of the undernutrition conundrum requires work to be done at the field level involving communities, households, families, individuals and caregivers for which a distinct local initiative is necessary. In addition, centralization of ICDS operations causes undue delays in the outflow of finances impacting implementation adversely. Empowered local groups are more likely to be successful in getting communities stimulated to confront the issue.
9. A study by UNICEF revealed that implementation of SNP for children aged 6 months to 6 years of age and pregnant and lactating women in Odisha and UP has suffered from a budget-resource deficit of 50 and 32% respectively. With a national budgetary provision of over 23000 crores for the year 2019-2020, it could be said that funds envisaged for SNP are quite adequate. But the failure in the implementation of the SNP in states like UP points to the way funds can be squandered through corruption which is a cause for grave concern. Also, financially sound States like those in the south are likely to allocate adequate funds for programs like ICDS but fiscally deprived states cannot afford to. Therefore, adequate attention has to be paid to ensure funds are made available in regions where high levels of undernutrition are prevalent.
10. Public service delivery systems like ICDS and primary health centers are plagued by non-filled in posts both at the supervisory and field worker levels and this reduces the competency levels at which these offices function. Recruiting manpower at all stages should be prioritized. Capacity building measures have to be taken up to enhance the skill sets and capabilities of workers and supervisors to ensure superior outcomes. The field workers have to be impressed upon the importance of height and weight measures of children for generating reliable data on levels of stunted, wasted and underweight children.
11. Positive child nutrition outcomes are vastly dependent on the efforts made by the field level workers and supervisors functioning at the ICDS. Many of them are responsible for some outstanding work that has resulted in reduction of child undernutrition levels in their areas. They have shown great fervour and resourcefulness in devising innovative methods for changing the lives of children and women under their care for the better. Incentivizing their work and more essentially entrusting financial powers to them for running the daily activities will in the long run bear exceptional results. Another aspect that requires serious consideration from the policy makers is the point of raising the honorarium paid to the field level workers which at the current rate is completely insufficient, considering the fact that they contribute immensely in their line of work. Also, since the ICDS has been in existence for almost half a century now and from the current scenario, it is likely to be here for a sustained time, serious thought is needed towards regularizing ICDS functionaries as government workforce. 

Conclusion
Despite years of public sector enterprise and initiatives, India still has much to achieve and improve with regards to the nutritional status of its population. Globally, India performs inadequately across standard child nutritional indices, ranking 102 out of 117 countries for child malnutrition according to the Global Health Index 2019. For positive nutritional outcomes, it is important to educate mothers and the grassroot level workers directly responsible for a child’s nutritional status, on the importance of the right type and amount of nutrition, encouraging the consumption of foods of diverse calorific value. The mid-day meal scheme in India, the largest of its kind in the world is a great opportunity which could be used to strategize and implement micronutrient fortification of foods to address deficiencies prevalent among children.  In addition to child undernutrition, the grave consequences of undernutrition among adolescent girls and women have long been recognized but little quantifiable headway has been made in resolving the distinctive concerns faced by this group.  It is crucial for the policy makers to recognize that the deprivation in terms of nutrition that adolescent girls and women face can boomerang on the society by producing an unhealthy generation of men and women in equal measure. Addressing child and maternal nutrition adequately can place India on the road to achieving the United Nations’ Sustainable Development Goals 1, 2 and 3 of no poverty, zero hunger and good health and wellbeing respectively.

References

  1. Blössner, Monika, de Onis, Mercedes. Malnutrition: quantifying the health impact at national and local levels. Geneva, World Health Organization, 2005. (WHO Environmental Burden of Disease Series, No. 12).
  2. Casadei K, Kiel J. Anthropometric Measurement. [Updated 2020 Jan 28]. In: Stat Pearls. Treasure Island (FL): StatPearls Publishing; 2020 Jan-Available from: https://www.ncbi.nlm.nih.gov/books/NBK537315/
  3. Mercedes de Onis and Monika Blössner The World Health Organization Global Database on Child Growth and Malnutrition: methodology and applications International Journal of Epidemiology 2003;32:518–526
  4. FAO, IFAD, UNICEF, WFP and WHO. 2018. The State of Food Security and Nutrition in the World 2018. Building climate resilience for food security and nutrition. Rome, FAO. Licence: CC BY-NC-SA 3.0 IGO.
  5. United Nations Children’s Fund, World Health Organization, World Bank Group. Levels and trends in child malnutrition: Key findings of the 2018 Edition of the Joint Child Malnutrition Estimates. p. 2018.
  6. World Health Organization . Reducing stunting in children: equity considerations for achieving the global nutrition targets 2025. Geneva: World Health Organization; 2018.
  7. Nie, P., Rammohan, A., Gwozdz, W., & Sousa-Poza, A. (2019). Changes in Child Nutrition in India: A Decomposition Approach. International journal of environmental research and public health, 16(10), 1815. https://doi.org/10.3390/ijerph16101815
  8. World Health Organization. WHA Global Nutrition Targets 2025: Wasting Policy Brief. Available at http://www.who.int/nutrition/topics/globaltargets_wasting_policybrief.pdf (Accessed March 19, 2020)
  9. Development Initiatives, 2018. 2018 Global Nutrition Report: Shining a light to spur action on nutrition. Bristol, UK: Development Initiatives.
  10. Stephen Morton, David Pencheon, Neil Squires, Sustainable Development Goals (SDGs), and their implementation: A national global framework for health, development and equity needs a systems approach at every level, British Medical Bulletin, Volume 124, Issue 1, December 2017, Pages 81–90, https://doi.org/10.1093/bmb/ldx031
  11. Michael Lokshin, Monica Das Gupta, Michele Gragnolati and Oleksiy Ivaschenko. Improving Child Nutrition? The Integrated Child Development Services in India. Development and Change 36(4): 613–640 (2005)
  12. Katiyar, S. P. (2016). Gender Disparity in Literacy in India. Social Change, 46(1), 46–69. https://doi.org/10.1177/0049085715618558
  13. Toteja, G. S., Singh, P., Dhillon, B. S., Saxena, B. N., Ahmed, F. U., Singh, R. P., … Mohan, U. (2006). Prevalence of Anemia among Pregnant Women and Adolescent Girls in 16 Districts of India. Food and Nutrition Bulletin, 27(4), 311–315.
  14. International Institute for Population Sciences (IIPS) and ICF. 2017. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: IIPS.
  15. Brinda Viswanathan 2014. Prevalence of Undernutrition and Evidence on Interventions: Challenges for India MONOGRAPH 29

Dr. K K Asha, Principal Scientist & Nodal Officer (HRD Cell), Biochemistry & Nutrition Division, ICAR-Central Institute of Fisheries Technology, CIFT Junction, Willingdon Island, Matsyapuri P.O., Cochin-682 029, Kerala

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May 20, 2020

Dr. K K Asha asha.santhosh5@gmail.com

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