New Delhi: Whether we take the recently published Global Hunger Index (GHI) 2019 into consideration or we take view of the UNICEF’s State of the World’s Children (SOTWC) report, the fact highlighted in these reports remains the same – India’s malnutrition issue. While GHI, a report that comprehensively tracks and measures hunger across the world, has ranked India 102 out of the qualifying 117 assessed countries. State of the World’s Children, on the other hand, has taken the Comprehensive Nutritional Survey into account to conclude that malnutrition is behind 63 per cent of deaths of children below the age of five in India. CNNS was conducted between 2016-2018 across India by UNICEF India and Ministry of Health and Family Welfare.
These reports came out after India observed the month of September as Poshan Maah under the Poshan Abhiyan. The Poshan Abhiyan has set the timeline of 2018-2022 to reduce child under-nutrition (stunting and underweight) and low birth weight by 2 per cent a year, and anaemia across age groups by 3 per cent a year, and create a mass movement for achieving a malnutrition-free India by 2022.
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Ministry of Women and Child Development implemented the Poshan Abhiyaan in 315 Districts in first year in 2018, 235 Districts in second year and remaining districts will be covered in the third year. The Abhiyan will act as an apex body that will monitor, supervise, fix targets and guide the nutrition related interventions across the Ministries.
According to Dr. R. Hemalatha, Director of ICMR – National Institute of Nutrition which comes under the Ministry of Health and Family Welfare, the methodology and criteria applied to calculate the Global Hunger Index may not be ideal while the data included is outdated. She explained to NDTV,
The 2019 GHI used four indicators – calorie inadequacy, stunting, wasting and under 5 mortality rate (U5MR) to compute the burden of hunger for GHI score; however, all the four indicators are interrelated and confounding. Calorie inadequacy may manifest as stunting and wasting, and children with undernutrition (stunting and wasting) may have higher frequency of disease burden and mortality. Hence, computing hunger index using these four indicators may actually be cumulative and distort the true picture.
She further added that in India, the available national data for stunting, wasting and dietary intakes are from NFHS4 (2015-16) and NSSO (2011-12), which are relatively old. The data of NFHS4 and NSSO may not represent the current nutrition scenario in India; and any computation from these data may not be totally relevant for hunger index score in 2019.
The recently generated CNNS (2018-2019) countrywide data shows decreased prevalence of both stunting (35per cent) and wasting (17per cent). Furthermore, micronutrient deficiencies that represent hidden hunger in children have reduced significantly. Also, the U5MR is decreasing at an annual rate of 5.1 per cent in India, which is a very positive sign.In a recent cohort study (2019, Plos), mortality rate among children with wasting (severe acute malnutrition) was only 1.2 per cent in India, as against the WHO’s estimates of 10 per cent–20per cent among children with wasting, she said.
Some of the developed countries data that have GHI score of <5have been included in the 2019 GHI, and hence other countries rankings have changed compared to previous ranking. The GHI 2019 document mentions that comparisons cannot be made between years and also between countries for ranking, as the data for some countries are older while for other countries more recent data have been included, Dr. Hemalatha claims.
When it comes to the UNICEF report, Dr. Hemalatha notes that the Under-five mortality rate (U5MR) is 37 for 1000 live births. Of the 37 U5MR, 62 per cent was due to neonatal (a child aged between 0 to 28 days) death (mortality).
As per the UNICEF report, the U5MR is decreasing at an annual rate of 5.1per cent. The neonatal mortality rate (NMR), which is contributing to 62 per cent of U5MR, occurring during the first one to three weeks of life may have a wide range of medical causes not necessarily related to nutrition. Thus, suggesting that most of these children in India with low weight for height/length (children with wasting) are not necessarily sick. Earlier studies in India also showed lower mortality among children with wasting. The disability-adjusted life year (DALY, a measure of overall disease burden) due to maternal and child malnutrition have also decreased by 64.3per cent, and overall disease burden has decreased by 36per cent, but obesity has been increasing in all age groups in all states, she asserted.
NDTV reached out to various experts to understand their outlook on the situation. Arjan de Wagt – Chief Nutrition – UNICEF India told NDTV that in the last few weeks, thanks to the newly available data and reports, the problem has been highlighted so prominently that calls for participation from all stakeholders. He said,
Looking at these reports and the reality highlighted here, my conclusion is that we know how big a problem malnutrition is, so now what are we going to do? Poshan Abhiyan identifies about ten interventions that include every child needing supplement thrice year, deworming twice year, among other such interventions. These policies and initiatives are in place and yet many children are not getting benefitted by these. Iron folic tablets are absolutely must for women, children and young girls to receive. The biggest problem faced by the Poshan Abhiyan is the population which resides in the harder to reach areas. Even if the government successfully reached 60 or 70 per cent people under Poshan Abhiyan, the most vulnerable group of people in the country are still excluded or miss out, when these are the people who are in the most need of these interferences.
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Mr. Wagt further acknowledged the government’s initiative of transforming the Poshan Abhiyan into a ‘Jan Andolan’ or a people’s movement, wherein, people’sparticipation is given the major importance.
UNICEF’s SOTWC highlights that it’s about eating nutritious food and that it’s the community who is responsible for the same. We need to look at it as a Jan Andolan where every parents, every child, every teacher, students, come together as a community to learn what nutritious food is.
Dr. Shweta Khandelwal, Head – Nutrition Research, Public Health Foundation Of India (PHFI), referring to the Global Hunger Index she explained that malnutrition is not a problem of hunger alone. She said,
While computational exercises and ranks like 102/117 help us get a comparative sense of where we are, it may not be the whole truth. India is being struck with multiple forms of malnutrition and hunger or undernourishment is one part of this story. Focusing on hunger alone will yield quick fixes like providing calorie sufficiency via more food without much attention to the quality of it.
On the other hand, Dr Suparna Ghosh Jerath, Head – Community Nutrition, PHFI and Additional Professor, Indian Institute of Public Health asserts on setting realistic targets and she explains that the policies at the topmost levels are good but we need to look at the policies at the grass root level. She said,
Facts and figures will not change overnight, but we have to set realistic targets, like reducing the rates of malnutrition by 2 or 3 per cent per annum. Even to achieve this, we have to work at the grass root levels of policy making. As we can easily set an agenda at the top most level, but the need of the hour is efficient monitoring at the grass root level, which is where we face the most amount of problems. We need to know how well our Anganwadi and ASHA workers are performing in the villages, and need to sensitise them to make them competent enough because at the end of the day, they will be our agents of change in the nutrition sector.
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Giving supplementary nutrition is not the solution, she further added,
We need to focus on providing Information, Education and Communication to the mother. At the end of the day, it’s the mothers who are care givers and provide nutrition to their children. Mothers should be counselled on nutrition education along with deworming, immunization and given livelihood security. She should have access to safe drinking water and hygiene and sanitation facility. The nutrition support system we create is what is going to make a difference in the society.
Dr. Suparna explained that some of the things that could help achieve the targets of malnutrition free India are – capacity building of the grass root workers, implementation and monitoring of policies at the lowest levels, nutrition education, sensitisation, transparency in the system.
Dr. Shweta on the other hand told NDTV about the kind of nutrition affected children should be provided,
We must not feed this abysmally high number of our underweight, stunted and/or wasted kids with carbohydrate rich foods and accelerate their transition into non communicable diseases (NCDs) in their later life. There are tons of studies showing strong linkages between early life nutrition and later life diseases. Thus my plea will be to focus on making healthy diets accessible to all throughout their life-course. This is the only way to redeem ourselves and get our act together. We must invest in making food systems sustainable and resilient and our food environments be rid of this deluge of ultra-processed high fat sugar salt foods. Let us have financial levers and other measures to incentivize heathy eating across any socio-economic strata. The collective force and joint efforts of research, academia and civil society to get the government to act in favor of balanced, healthy foods is the urgent need of the hour.
Some of the other things we noticed while analyzing the data was that malnutrition is not an isolated problem as it is very deeply connected to other issues such as sanitation, water quality also very closely linked to maternal health, since these are young children and they have the issues of wasting and stunting is due to chronic under nutrition. We also saw the trends on district level analysis, so the districts with low literacy levels, poor gender ratio and a high rate of underage married women and mothers; are the districts where the hunger index is poorer. Of course food availability is an issue but it is joined by multiple other factors, so it is a long term problem and therefore the solutions have to be thought of in a much more realistic manner. Even if food is made available to these children, it won’t make a difference overnight.
She further noted that the Breastfeeding campaign have yielded amazing response as breastfeeding is a key factor in terms of curbing malnutrition. Ms Bansode asserted that even if don’t compare India’s ranking in GHI with other countries, our standalone numbers are still very poor and we still have a long way to go.
Dr Arun Gupta, Central Coordinator, Breastfeeding Promotion Network of India (BPNI), expressed his disappointment with the malnutrition data recognized through the recently published reports, he said,
How can we aim to do bigger and better things with the nation if our own children are hungry and malnourished. It is a shameful thing to have such figures. We do have the Poshan Abhkiyan to help improve our current situation and we do promote the importance of first thousand days in a child’s life to stop new cases of malnutrition – but do we explain it to the people that these thousand days also include the pregnancy period, as it is very crucial? The first year where the brain is developing, nutrition is paramount at the time. Government says it’s a behavior problem but shouldn’t government focus on making these issues vanish by attempting to reach more and more people. We need a more comprehensive approach to curb malnutrition and the Poshan Abhiyan will only work if the political will and people’s participation go hand in hand.
Mr. Wagtt from UNICEF India told NDTV that the Women and Child Development Minister Smriti Irani, at nutrition council meet a few weeks ago, noted the necessity of scaling up the Poshan Abhiyan at block level, village level and district level, to be able to figure out the group and community of people who are missing out on the facilities being provided by the government. He further appreciated initiatives like Ministry of Human Resource Development instructing schools in rural and urban areas to set up kitchen gardens in the campus to teach students about nutrition.
The government is indeed trying, it’s not just one ministry who can do such a mammoth task alone, and it requires government’s will from different departments. Like women child development has Poshan Abhiyan, HRD Ministry and Education has come up with nutrition garden and Health Ministry will have to tackle diarrhea, which can lead to malnutrition. So its not just the job of one ministry but different sectors realizing were they can chime in to help. We need to educate children about nutrition and they can take that information home. The children can teach parents, grandparents and relatives and the scope just remains endless. This is why I love and support the idea of Jan Andolan which means it ultimately has to come from the people and they have to change or realise the need to change. The idea of introducing nutrition at school and mobilising school students across the nation may be a game changer, Mr. Wagt signed off.
