by Ravi Shankar Behera and Dr. Ranjit K. Sahu

India experiences a malnutrition burden among its under-five population. As of 2015, the national prevalence of under-five overweight is 2.4%, which has increased slightly from 1.9% in 2006. The national prevalence of under-five stunting is 37.9%, which is greater than the developing country average of 25%. One of the major causes of malnutrition in India is economic inequality. Due to the low social status of the population, their diet often lacks both quality and quantity. Women who suffer from malnutrition are less likely to have healthy babies. The high proportion of child under-nutrition, combined with the large population base, has made India the country with the largest number of stunted, wasted, and underweight children in the world.

According to a recent United Nations Children’s Fund (UNICEF) estimate, India accounts for 31 percent of the developing world’s children who are stunted and 42 percent of those who are underweight. UNICEF data show that about 47% of Indian children under 5 are underweight; the corresponding figure for sub-Saharan Africa is 24%. Poverty is one of the major causes of low dietary intake and malnutrition. Most food insecure and vulnerable people suffer from malnutrition, morbidity, disease, and micronutrient deficiencies.

The availability and access to diversified and nutritious balanced food is the key, at the household level. This includes local foods and wild foods from the forest, comprising of Minor Millets, greens, unpolished rice, vegetables, tubers, oilseeds, and fruits. The change in food habits of people, moving towards Rice, Wheat and other processed foods have had an adverse impact on the nutritional security aspects. Another critical factor is the extent of absorption of nutrients from the food consumed in the body. Some of the other key factors which are interlinked with the issue of malnourishment are access to clean drinking water, personal hygiene practices, improved Sanitation, diseases and epidemics, clean living environment, disinterest among tribal communities to avail Government health and nutrition services at hospitals and Nutrition Rehabilitation Centres (NRCs), etc.

Malnutrition is to be seen as an intergenerational issue. The cycle starts from the fetus in the mother’s womb, childbirth, early care, adolescence, youth, and old age. Anemic mothers give birth to babies with low birth weight and malnourished children, who are prone to a plethora of infections and diseases.

The key areas of focus to prevent malnutrition should be on the first 1000 days of life, which is crucial for their growth and development, including the development of the brain of the child. Initiation of breastfeeding within an hour of birth, exclusive breastfeeding for first six months of life, starting complementary feeding at the completion of six months and continue breastfeeding at least till two years of life, provision of diverse and good quality complementary foods, will give a child a right start to have a healthy life. Reduction of anemia among children, adolescents, and women through ‘test, treat and talk’ activities and promotion of healthy diets rich in Iron, protein, and Vitamin C is critical.

The major nutritional problems are Protein Energy Malnutrition (PEM), Vitamin A deficiency (VAD), iron deficiency anemia (IDA), and iodine deficiency disorders (IDD). The major Nutrient deficiencies are Pellagra (Niacin), Scurvy (Vitamin C), and Iron-deficiency anemia (Iron). Iron deficiency is the most common and widespread nutritional disorder in the world. As well as affecting a large number of children and women in developing countries. The two major nutritional problems in India are (i) Under Nutrition (Underweight – 43.5, Stunting – 47.9, and Wasting – 20) and (ii) Nutritional Anaemia (<5 years – 74.3%, and pregnant women – 49.7%).

Hunger Pockets

There are many hunger pockets in India. These are typically “high energy-deficient zones”. Some of the endemic hunger pockets include the entire Chota Nagpur plateau including the regions of Palamau-Garhwa-Latehar region in Jharkhand, Bastar region in Chhattisgarh, and Kalahandi-Balangir-Koraput (KBK) region in Odisha. The other hunger pockets are the Bundelkhand region in UP, Vidarbha region in Maharashtra, Jhabua, and Raigad in MP, North Bihar region, and so on. Some of the most marginalized and excluded scheduled caste and scheduled tribe communities like the Mushahars, Primitive Tribal Groups (PTGs), Nomadic Tribes, etc. live in such regions, who constantly face the issues of chronic hunger and acute malnourishment on a day-to-day basis.

Some of the worst districts in India, where the incidence of Malnourishment is high include Kalahandi, which has 60 percent of children having some form of nutritional deficiency. About 37.6 percent of children have Grade I (i.e., mild) malnutrition and 22 percent have Grade II (i.e., moderate) malnutrition.  About two percent of children have Grade III and IV (i.e., severe) malnutrition. About 53.8 percent children, 11.2 percent adolescent girls, and 33.3 percent pregnant women report mild anemia in Kalahandi.  Also, about 39.8 percent of children, 57.8 percent of adolescent girls, and 66.7 percent of pregnant women report a moderate form of anemia, and 3.2 percent of children and 29.5 percent of adolescent girls suffer from a severe form of anemia.

Creches, Nutrition and COVID

Community-level institutions can ensure that the burden of malnutrition is not aggravated during the pandemic. Besides wreaking havoc in the healthcare space, the COVID-19 outbreak has also caused a setback in other developmental areas, including those related to the removal of poverty and improving nutrition. Even as responses are mounted to keep the pandemic in check, other serious problems loom large. As per, “The State of the World’s Children 2019, UNICEF”, before the COVID-19 outbreak, malnutrition was the cause of 69 percent of the total deaths of children under five years. India was home to nearly half of the world’s “wasted” (low weight for height ratio) children. The report also highlighted that only 42 percent of infants in the age group of six to 23 months were fed at adequate intervals, and only 21 percent received an adequately diverse diet. Given the significantly high number of malnourished children already present in the country, screening, and treatment of all at-risk cases in hospitals is not feasible. With government support schemes coming to a standstill during the pandemic, and an economic crisis that has led to over 120 million people losing their jobs, UNICEF warns that an additional 3 lakh children will die in India unless health services and nutritional support is quickly reinstated.

Strategies to combat Malnutrition in India

Eliminating malnutrition has been a difficult target for India. However, measures taken over the last few years have given development sector experts hope. In Odisha, for instance, over the last few years, the local authorities have taken steps to improve nutritional outcomes. Community-based crèches have been planned for implementation to ensure improved health management of children under three years. These crèches will provide community-based management of SAM (CMAM), supervised feeding, and counseling for mothers and children with moderate acute malnutrition.

The community-based approach involves the timely detection of SAM in the community and provides treatment for uncomplicated SAM cases through ready-to-use therapeutic foods or other nutrient-dense foods. If combined with a health facility-based approach for those malnourished children with medical complications or below six months and implemented at scale, community-based management of severe acute malnutrition could prevent the deaths of thousands of children. Half-yearly screenings and diligent tracking of malnourished children helped in the timely management of malnutrition. As part of the initiative, supplementary hot cooked meals were also provided to pregnant women and lactating mothers, in addition to the existing nutrient fortified ‘Take Home Ration’ (THR) provided under the ICDS supplementary nutrition program.

Strategy for Odisha’s pathway to accelerated Nutrition (SOPAN) also makes an effort to improve accessibility for nutrition services by mobilizing mothers’ groups via the “Pada Pusti Karyakram” and by deploying Pusti Sakhis, or nutrition helps from the community, in hard-to-reach areas. Training centers for Anganwadi workers are being upgraded to Centres of Excellence (CoE) to give the initiative the direction and support it needs. Moreover, dialogues of interdepartmental convergence and partnerships within the state are underway to ensure positive nutrition outcomes for the future. However, there is much scope for improvement in such state-level interventions. For instance, SAM management is driven by the Health department in some states and the Department of Women and Child Development in others. This indicates a lack of ownership in addressing malnutrition at the governance level. Uniformity in the implementation framework at all levels needs to be adopted stringently to build an administrative will to address the burden of malnutrition. This should be taken up by the Department of Women and Child Health and adequately supported by the Health Department for effective implementation strategies.

Given the dire situation of our nutrition indicators and the resource-crunch brought on by the pandemic, the best way forward would be to minimize the burden of malnutrition cases on hospitals by resolving less severe cases at the community level by engaging the frontline workforce such as Anganwadi workers and institutions like the Nutrition Rehabilitation Centres (NRCs) at the community level efficiently.

National guidelines would be imperative in highlighting successful models across the country and for establishing a proper continuum of care, i.e., from the home and community to the health center and back again in cases with medical complications. Mothers, new-borns, and children are inseparably linked in life and health care needs. In the past, maternal and child health programs addressed the mother and child health issues separately, resulting in gaps, which especially affected the health of new-born babies. Continuum of care can be achieved through a combination of well-defined policies and strategies to improve home care practices and health care services throughout the lifecycle, building on existing programs and packages. An effective continuum of care strengthens the links between the home and the first level facility and the hospital, assuring appropriate care for beneficiaries. Strategies involve improving the skills of health workers, strengthening health system supports, and improving household and community practices and community actions for health. This approach also brings care closer to the home through outreach services and promotes referral by strengthening access to and improving the quality of health services. Combining effective care in health facilities, healthy behavior at home and early care-seeking for illness will have a significant impact on mother, new-born, and child health. If all stakeholders at the Centre and State-level work together at an accelerated pace, only then can India hope to steadily improve its nutrition indicators and eventually eradicate malnutrition.

 Innovative Initiatives by Government and Civil Society Organizations (CSOs) to Combat Malnutrition

POSHAN Abhiyaan: In order to bring nutrition to the center-stage of the National Development Agenda, the Government of India launched Poshan Abhiyaan, a multi-ministerial convergence mission with a vision to address malnutrition in a targeted approach. Since the launch of the POSHAN Abhiyaan by the Centre in coordination with the states, there has been an increasing momentum to implement comprehensive plans for the identification and treatment of children with Severe Acute Malnutrition (SAM), and exploring innovative solutions for dealing with this nutrition disorder within the ambit of government programs. The ‘Poshan Maah’ programs are being held across the country but certain innovations have been taken up in Madhya Pradesh, important among them being target-based activities for children, women, adolescent girls, and men every Tuesday – a practice that will continue beyond the ‘Poshan Maah’. To ensure community mobilization and bolster people’s participation, every year the month of September is celebrated as Rashtriya Poshan Maah across the country. Also, activities like ‘Miss Haemoglobin’ contests for adolescent girls where girls with the highest hemoglobin levels in particular schools are given the titles ceremoniously are being held to emphasize the importance of reducing anemia. The promotion of “Nutri-Gardens” in rural areas has also proved beneficial to grow vegetables, greens, and other crops to ensure food and nutritional security of the most marginalized sections of the society.

Dastak Abhiyaan: An Innovative Preventive Strategy for Addressing Mortality in U5 Children in Madhya Pradesh has laid emphasis on evidence-based planning and using data as a tool for evaluating the progress of health service delivery. It is globally accepted that protocol-based SAM management, optimal IYCF practices, addressing children with severe anemia, preventing childhood diarrhea & pneumonia can make a significant dent in U5MR. Hence, the emphasis of the State is to shift focus from facility centric care to preventive and promotive aspects of health care targeting the major determinants of child mortality in the State. As a pilot strategy to actively screen children with severe anemia using WHO color scale, severe acute malnutrition by MUAC, critically sick children and those with pneumonia as per IMNCI signs along with counseling of IYCF services under MAA program, demonstration of hand washing steps / ORS preparation at the community doorstep. In addition, to prevent iodine deficiency disorders in mothers and children, testing of salt for iodine adequacy was also in-built into the Dastak strategy.

Anemia reduction: A new approach to improve the micronutrient content of home-prepared complementary foods. The burden of IDA can be reduced by taking a holistic approach that would include the promotion of healthy weaning practices and the use of appropriate complementary foods, together with improving the nutritional value of such foods. To improve the nutritional value of home-prepared complementary foods, “Micronutrient Sprinkles” in a powder form should be developed as a home-fortification strategy for improving the nutritional quality of home-prepared complementary foods. Promotion of regular consumption of foods rich in iron, provisions of iron and folate supplements in the form of tablets to the high-risk groups, and identification and treatment of severely anemic cases are effective interventions for anemic patients.

Under-Nutrition: The broad prevention strategies include the promotion of Optimal Feeding of Infants and Young Children; Indian mothers tend to breastfeed until about two years and do not add semi-solid complementary foods to children’s diets, perpetuating the calorie and protein gap; Multiple approaches exist to promote the initiation of breastfeeding and to prolong exclusive breastfeeding: health education, professional support, lay support, health sector, and media campaigns through health facilities and community programs.

Disease Control and Prevention: Interventions to prevent or decrease malnutrition or infectious disease are expected to decrease child mortality, and interventions that accomplish both will have the greatest effect include Water, sanitation, and hygiene interventions decrease childhood malnutrition primarily by preventing diarrheal disease; Hand-washing interventions can reduce the risk of diarrheal diseases by about 45 percent. Hand-washing interventions can be included in water and sanitation programs or can exist as a single intervention, and they are both effective and cost-effective.

Pada Pusti Karyakram: The project is aimed to improve the access to Dry food ration for children under 5 from the nearest Anganwadi centers and distribute it to eligible children/families in remote and inaccessible villages. In Odisha, hamlets can be seen in large numbers in the districts of Kalahandi, Koraput, Rayagada, Malkangiri, and Nabarangpur. Many infants and children suffer from malnutrition and related diseases due to a lack of nutritious food. Since most of the hamlets are located in untrodden and inaccessible hilly terrains and forests, the government delivery system fails to reach them. Apart from the nutritional requirements that are being met, the children at Pada Pusti centers will be taught by trained volunteers. Like in government-run Anganwadi centers, the children are given free clothes and books. Pusti Sakhis (Community Resource Person to be deployed in Hard-to-Reach areas) will act as a link between the Anganwadi centers and the community to ensure the timely availability and access of dry ration and other services. Pusti Sakhis will be oriented on the roles and responsibilities of Anganwadi centers, ICDS services, including nutrition and health services. Mothers Groups will support the project to ensure the last mile connectivity of the Anganwadi centers in operational villages and be engaged in the preparation of hot cooked meals and feeding of the children under 5 years.

Nutri-Gardens: MS Swaminathan Research Foundation (MSSRF) in collaboration with the Integrated Child Development Scheme (ICDS) has undertaken multidimensional efforts to reduce child malnutrition. In this regard, a program on ‘Anganwadi Nutrition Garden’ is being supported to demonstrate model Anganwadis in the operational districts for profound child nutrition outcomes and improved nutrition literacy. Many states in India like Odisha, Kerala, etc., are now promoting the concept of Nutri-Gardens and backyard gardens in their Anganwadi programs.

Public Distribution System (PDS): It ensures the availability of essential commodities like rice, wheat, sugar, edible oils, and kerosene at subsidized rates to identified consumers through a network of outlets or Fair Price Shops (FPS). A large section of the district has accessibility to PDS commodities.

Supplementary Nutrition Programme (SNP): This program is implemented in Kalahandi at 1,263 centers.  Under SNP, ready to eat food called “Orimix”, which is composed of wheat, soya bean, and sugar in the ratio of 65:15:20 and fortified with vitamins and minerals is provided to beneficiaries consisting of pregnant, nursing mothers and children aged between 0-6 years. Under the program, 80 grams of Orimix is provided to the beneficiaries for 25 days in a month along with the oil is provided. Severely malnourished children, pregnant and nursing mothers are given double rations.

Emergency Feeding Programme: Under this, cooked food is provided to aged persons, who do not have any social security system at the family level.

Mid Day Meals (MDM): The Mid-day Meal Scheme is a school meal program of the Government of India designed to better the nutritional standing of school-age children nationwide. The program supplies free lunches on working days for children in primary and upper primary classes in government, government-aided, local body, Education Guarantee Scheme, and alternate innovative education centers, Madarsa and Maqtabs supported under Sarva Shiksha Abhiyan and National Child Labour Project schools. Serving 120 million children in over 1.2 million schools and Education Guarantee Scheme centers, it is the largest of its kind in the world. Under this program, cooked food is provided to students in Classes I-V. This program serves two objectives: (i) encouraging more enrollments, and retention of students in primary schools, and (ii) improving the nutritional status of students.

NGOs and Civil Society groups are also involved in addressing the issues of malnourishment at grassroots and various levels. Some of the notable initiatives include the promotion of Breastfeeding, Handwashing campaign, promotion of local nutritious food and recipes, including vegetables, greens, tubers, fruits, promotion of wild foods, awareness campaigns on health, hygiene, and nutrition, supporting the Government-run nutrition schemes and programs at the grassroots level like Pada Pusti Karyakram, implemented by local NGOs, Mid Day Meals program by women SHGs etc.

CSR Foundations are also supporting some of the food and nutritional security programs in India. Some of the prominent CSR Foundations include Azim Premji Philanthropic Initiatives (APPI), which has a clear focus to address issues of nutrition, working in close collaboration with the State Government and other Voluntary Organizations. Some CSR Foundations have signed Statement of Intent (SOI) with the State Governments and Niti Aayog to work in the Aspirational districts (poorest districts) of India with a focus to strengthen the Government institutional frameworks and nutrition services.

About the Author:

Dr. Ranjit K. Sahu is a Research professional and freelance writer with over a decade of experience in biomedical research, currently located in Virginia, USA. His interests include education, environment, sustainability and health care in the underprivileged regions of the world.

Ravi Shankar Behera is a freelance consultant in the development sector and affiliated to several organizations, currently based in New Delhi.