Shailaja Chandra writes: The irony is that issues related to nutrition and their solutions, although they appear simple and cheap, need delving into individual homes. (CR Sasikumar)Every October, the Global Hunger Index (GHI) is released. It generally creates an uproar, and with good reason. But this time it has gone overboard. The fountainhead is a 16-year-old German and Irish organisation, which measures and ranks countries on a hunger index at the global, regional, and national levels, but not at the sub-national level where some Indian states fare better. The GHI’s stated aim is to reduce hunger around the world. But its methodology focuses disproportionately on less than five-year-olds.
In common parlance, hunger and nutrition are two different things. Hunger is associated with food scarcity and starvation. It produces images of emaciated people holding empty food bowls. GHI uses childhood mortality and nutrition indicators. But its preamble states “communities, civil society organisations, small producers, farmers, and indigenous groups… shape how access to nutritious food is governed.” This suggests that GHI sees hunger as a food production challenge when, according to the FAO, India is the world’s largest producer and consumer of grain and the largest producer of milk; when the per capita intake of grain, vegetables and milk has increased manifold. It is, therefore, contentious and unacceptable to club India with countries facing serious food shortages, which is what GHI has done.
The sensational use of the word hunger is abhorrent given the facts. But there is no denying that in India, nutrition, particularly child nutrition, continues to be a problem. Unlike the GHI, the National Family Health Survey (NFHS) does a good job of providing comparative state-level data, including the main pointers that determine health and nutrition. NFHS provides estimates of underweight, (low weight for age), stunting (low height for age) and wasting (low weight for height). These conditions affect preschool children (those less than 6 years of age) disproportionately and compromise a child’s physical and mental development while also increasing the vulnerability to infections. Moreover, undernourished mothers (attributable to social and cultural practices,) give birth to low-birth-weight babies that remain susceptible to infections, transporting their handicaps into childhood and adolescence.
The jury is divided on the causes and solutions. Leela Visaria, a noted sociologist, links the nutritional status of young children with the post-neonatal phase when children suffer from acute respiratory infections and diarrhoeal diseases. Sanitation and hygiene require much more work, she says. The Director of the Nutrition Foundation of India Prema Ramachandran says, “the Body Mass Index test is the best way of identifying both thin and overweight kids and the ongoing Poshan Abhiyaan envisages this.” Professor V Subramanian at the Harvard Chan School of Public Health writes, “there is a need to declutter the current approaches to child undernutrition by keeping it simple. I advise against a disproportionate focus on anthropometry (body measurements); instead, the need is to have a direct engagement with actual diet and food intake.”
The irony is that issues related to nutrition and their solutions, although they appear simple and cheap, need delving into individual homes. The first child nutrition challenge relates to breastfeeding. The WHO and UNICEF recommend that breastfeeding should be initiated within the first hour of birth and infants should be exclusively breastfed for the first six months. According to NFHS 5, in India, the percentage improvement of children who were exclusively breastfed when under six months, rose from 55 per cent in NFHS 4 to 64 per cent in NFHS 5. That is progress, but it is not enough. By not being breastfed, an infant is denied the benefits of acquiring antibodies against infections, allergies and even protection against several chronic conditions. NFHS says that only 42 per cent of infants are breastfed within one hour of birth, which is the recommended norm. Interestingly, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha and Maharashtra, Manipur, Rajasthan, Himachal Pradesh, and Haryana score above 70 per cent whereas the ones below 50 per cent include Bihar, Punjab, Kerala, Tamil Nadu, and West Bengal. The others are in between.
The second issue relates to young child feeding practices. At root are widespread practices like not introducing semi-solid food after six months, prolonging breastfeeding well beyond the recommended six months and giving food lacking in nutritional diversity. NFHS 5 shows that the improvement has been marginal over the last two reports and surprisingly, states like Maharashtra, Rajasthan, Assam, UP and Gujarat are at the tail end.
The feedback from a 40-year-old NGO CHETNA (with whom the writer is associated), which works for women’s and children’s health and nutrition across three states (Gujarat, Madhya Pradesh, and Rajasthan) is revealing. The NGO echoes the findings on breastfeeding and young children’s feeding practices, not through surveys, but by observing what goes on within the homes. Young children are allowed to run around while eating, exposing the food to flies, dust and heat. The NGO also found that children are weaned on watery liquid from cooked grain when they need energy and nutrition-dense food to develop. Even one teaspoon of ghee or oil added to semi-solid dal or khichri can provide adequate protein and calories, But mothers are ignorant of this. Equally, diversity in diet is important. Families start kitchen gardens and some even rear poultry once they are taught how nutrition can be improved.
The third issue is the outcome of poor nutrition. According to NFHS 5, the percentage of stunted, wasted and underweight children is 36 per cent, 19 per cent and 32 per cent respectively. It is worrisome that states like Bihar, UP and Jharkhand have fallen from their own levels five years ago. Overall, there has been an eight percentage point increase in children suffering from anaemia — from 59 per cent in NFHS 4 to 67 per cent in NFHS 5. This has a lot to do with the mistaken belief that manufactured snacks are “good food”. Anecdotally, there are reports that households in Dharavi, Asia’s largest slum, spend up to Rs 30 per day on packaged snacks like chips, papad and other over-salted edibles. Parents allow the child to sleep on an undernourished (virtually empty) stomach. CHETNA found the same phenomenon in urban slums and in villages and lamented that the same Rs 5 spent on manufactured snacks would be better spent on buying one egg.
Almost one dozen nutrition programmes have been under implementation since 1975. Several more have been added of late, but most beneficiaries of these food distribution programmes are kids attending anganwadis or schools, adolescents, and pregnant and lactating mothers. This must continue but newborns, infants, and toddlers need attention too. Monitoring weight is an indicator, not a solution. India has successfully overcome much bigger problems — reduced maternal and child mortality, improved access to sanitation, clean drinking water and clean cooking fuel. We should lose no more time over the GHI rankings, which are distorted and irrelevant. Instead, states should be urged to examine the NFHS findings to steer a new course to improve the poshan practices for the youngest and the most vulnerable sections of society: Helping mothers to better the lives of their infants and toddlers right inside the home by measuring and demonstrating how much diet, food intake and child-rearing practices matter.
The writer is a former secretary in the Ministry of Health