Coverage, continuity, intensity & quality, key challenges of malnutrition in India: UNICEF

Malnutrition in India is not limited to rural areas, rather it is highly prevalent in key metros like this child in New Delhi (MIG Photos/Aman Kanojiya)

India is home to the largest number of children suffering from malnutrition and stunted growth. This has been the case for decades. What has not been happening right?

I am an optimist. Things are going in a right direction. Malnutrition is improving but my concern is that they are not improving quick enough. If you look at children under 5, half of the children are too thin or too short. It basically means that they didn’t have the right nutrients to give them the height they could have. That is not genetic.

There is a thinking that Indians are short. But no, there was a study done on second generation Indians living in London, and they are as tall as the fellow people in London. Too short can also mean that they have got stunted immune development and are more susceptible to illnesses and high immortality rate. They also have stunted brain development, that also means that it is irreversible. If the brain development does not happen in the first two years, it is lost forever. The children go to school at 4-5 years but they are going with a lower IQ. The learning potential is lower that can have a lifetime impact. It’s a continuous cycle brought from one generation to other generation.

In India the policies and guidelines are brilliant. There are very few countries that have got such great policies, programmes and schemes. Let’s take Integrated Child Development Services (ICDS) for example, that is about 50 years old. You have Anganwadi workers, Community workers providing food, counselling and support. If I had to design them as a technician, I wouldn’t do much better than what they have. It’s not really about the design but about the implementation. First of all, the coverage. You don’t reach all the children that need it. With all the programmes that you have – from ICDS, to take home ration, to school feeding, counselling of mothers, you only reach part of them.

Also, the continuity of the service. It can be seen during Covid-19 that continuity had stopped. But even before the pandemic, we have seen that there were breakdowns in the supply of Vitamin A or iron folic acid and breakdown in take home rations. There could be strikes of frontline workers. So, the continuity of services is not always there. The third is what I call intensity. Government can only do when it comes to counselling nutrition but in the end it’s the parents that provide the food to the child. The parents need intense education on nutrition. Everyday, I find advertisements about Coca Cola, Pepsi, noodles and other junk food. These are advertised all over, but where can one see the ad for something that’s healthy to eat or breastfeeding or even how much nutrition is needed by a child. We need to intensify the awareness raising.

The fourth issue is quality of food provided. The nutrient quality of foods being delivered through various government programmes needs to be improved. So, what’s missing sometimes in India is Coverage, Continuity, Intensity & Quality.

What is the government not throwing enough at the problem? Is it money, expertise, trained manpower or awareness? You already mentioned awareness, do we have enough of the other elements?

For me, the number one issue is leadership. Countries that have been able to make significant gains in malnutrition, in a short time frame, I mean 5-6 years, are those with leadership. India is doing well. March 8, 2018, Prime Minister went to Rajasthan to launch Poshan Abhiyan. So when I was driving back to New Delhi, I was wondering if this was just another campaign. But I was wrong. For a month, the PM spoke of nutrition everywhere and so were the ministers and chief ministers of states. In September 2018, we had the Poshan Maah, Nutrition Month and that again meant that all over the country there was talk of nutrition everywhere, on television, in magazines, newspapers, everywhere. Before, we were missing that kind of leadership. Money is not necessarily the biggest issue, leadership and continuous focus is.

Arjan de Wagt, Chief Nutritionist of UNICEF

But did the message reach everywhere in the country or was it limited to the urban areas?

Fair enough, but did you know that 60 pc of all malnutrition cases of Maharashtra are in urban areas. We tend to ignore the urban areas thinking they are aware and better off than the rural folk and hence don’t need our attention. Overall you will see that states where malnutrition rates are lower, the leadership is better.

Besides leadership and money, the next important thing is infrastructure. Let’s be the honest, if you compare functioning infrastructure in UP or Bihar with that of Kerala or Tamil Nadu, you have big steps to take there as well. But I don’t think that putting adequate money in improving infrastructure without an adequate leadership is missing; what’s missing for me is accountability and use of data.

If you check internet and look for data on states, districts or block level as to what is the number of children receiving Vitamin A or Iron Folic Acid or even counselling for parents, this data is hard to come by. But you need this information on real time basis so you can see where the intervention is not working and how to improve it. But again for that you need leaders who will ask these questions. But if no one asks for the data, then no one will act. So it comes back to the issue of leadership. So for the last two years, under Poshan Abhiyan these questions were being frequently asked up to March this year. Then Covid-19 came and everyone only talked about it and no one talked about anything else. I am extremely biased being a nutritionist, and for nutrition is indeed the most important issue at all times.

Last year, Lancet carried an article saying that two-thirds of infant mortality in India was linked to malnutrition. It said that a million children under 5 years of age were dying every year in India. That means over 1800 children dying every day.

How has Covid-19 impacted malnutrition?

Because of Covid-19, three things happened. One is increase in poverty leading to increasing food insecurity and compromising on quality of food, as good fruits and high nutrient food is not the cheapest to buy. Second effect of Covid-19 was access to services, as a lot of them were severely disrupted at least during the lockdown and that means that a lot of people didn’t benefit from the services. The third factor was that the leadership disappeared as the focus of the leadership moved from malnutrition to Covid-19.  But happily, that has changed now. September became the Poshan Maah and we see that it has brought nutrition back on the agenda. I really hope this remains. We need coverage, continuity, intensity and quality.

According to global modelling, malnutrition rates would easily have increased 10-20 pc during the Covid-19. So, things had been going well for two years, but now we could risk losing the gains of not just the last two years, but the last five years or even more, if we don’t get things right quickly.

Which of the initiatives launched in Poshan Maah has been effective?

The campaign of 1000 days and the complementary feeding and breastfeeding weeks. There are two top reasons why children are malnourished. One mother is malnourished. A lot of children, about 20-25 pc, are born malnourished and they never fully recover. We need to address the issue of maternal malnourishment.

Second part is breastfeeding is not perfect and we need to improve it. But particularly what’s happening from 6 months onwards is that the breast milk alone is not enough. Mothers tend to give the child food too late, but even when they give the food, it is not child’s food, it is the family food. Family food is for families. Adult food is for adults. Babies need baby foods. It is not the stuff in shops. It means you mash potatoes, rice, some vegetables and fruits, some extra oil. It is important to educate people about the importance of complementary feeding.

One of the priorities of the Poshan Maah was indeed complementary feeding as well as the maternal nutrition. We need to get this right to tackle malnutrition. We need to educate parents and mother-in-law about the kind of baby food. We need to continue our communication to bring about a behaviour change.

The third issue was severe acute malnutrition or wasting, which means that a child is extremely thin and it does not have any nutrients to spare. It is an area that has not received adequate attention for the last decade or so. A child with wasting only needs a bout of diarrhea or respiratory illness to die. It is the most dangerous kind of malnutrition and it is the most important cause of child mortality in malnutrition. This was the first time that we focused on the issue. In India you have the system and the resources to ensure that no child with wasting has to die.

Our PM has his favourite themes for some particular moments and then he will move on to some other issue and will the entire bureaucracy. So will this impact continue?

I was worried about Covid-19 because of Covid there would be severe impact on malnutrition and it would take away all the leadership we had seen and without leadership the action on the ground would not happen. The PM talking about, the allocation of funds and the focus of the administration. It is all interlinked. People wanting to work on this is one thing, but when the leader decides to talk about it because it is an issue, it becomes more important and urgent. We need lots of champions for nutrition. The focus has been there for 2.5 years and I am afraid that the problem is too large to ignore even now as 1 million children are dying each year.

Malnourishment in women starts with adolescence and becomes acute during pregnancy in absence of a proper, a nutrient rich diet leading to a malnourished infant at birth

Is a girl child more prone to malnutrition than the male child?

The Ministry of Women and Child Development raised the issue of gender in March during the Poshan Pakhwara and it was the first time that I really saw the government take up the gender issue, but this needs to be taken up consistently as once is not enough. Is there a problem? Yes. Why are pregnant women getting malnourished babies? Because they are malnourished themselves. Why are pregnant women malnourished, not because they are pregnant; they were malnourished before they got pregnant.

When did they get malnourished? If you look at the data, they did not get malnourished in the first one or two years of their life. At a very young age, there is no difference in rates of malnutrition in girls or boys. At a later stage, the difference comes in. You see a big difference particularly during adolescent years. Also, biological needs start to differ as well. When girls start to menstruate they need iron folic acid as they lose lot of blood and that’s why anaemia is a problem that starts in adolescent girls. Anaemia has a big relationship with malnutrition. Anaemia leads to malnutrition and malnutrition contributes to anaemia, so it becomes a vicious cycle.

So it is from adolescence that you start seeing the difference and you also know very well that the cultural practices of feeding girls from a certain age lesser than the boys and malnutrition then really starts from adolescence and you see these malnourished girls get pregnant very early even when they are not yet fully grown themselves. We are very supportive that girls should not get pregnant too early. Let’s delay that, let the girl be fully grown herself and give a couple of years more for her to get truly nutritious food.

Has the situation about access to service for malnutrition changed after the lockdown was eased?

Ministry of health says that access to services was severely disrupted in April and May, but since then it has picked up and perhaps now the access to services is back to pre-lockdown days, but the offtake is not happening. So, the service may be there but you are not reaching everyone.

Are people aware of issue of stunted growth?

No, people here tell me Indians are short. I am an average Dutchman, but here in India when I am in an elevator with others, I am so tall. But second-generation Indians in London are taller than the average Indian here. And even babies who are adopted in Europe, they grow to be taller than people here. So, I think that people need to understand that it is a stunted immune system and stunted brain development. If you want to invest in children being educated, invest in their first 1000 days of life first. Because the biggest damage is caused in these days with a poor diet. It leads to lower IQ and you can send them to any university, but they can never do well as some of the connections in the brain are not fully made and that stays for life.

But stunting is something that even the rich are not aware of. There is a lot of stunting even in the richest 20 pc of the children. So it is not income, it is awareness. India is also getting increasingly obese children. So, you see stunted adults who are obese and I can guarantee that their micronutrient levels are poor. I want rich people to be concerned about nutrition as well because when they talk of nutrition, it comes in media and it trickles. It is a problem of the whole society.