India has been making significant investments in achieving food and nutrition security through structured public-funded programmes. In fact, India entrenches the right to food in its Constitution. Article 47 of the Constitution mandates the State to raise the level of nutrition of its citizens. India’s flagship nutrition programme-the Integrated Child Development Services (ICDS) Scheme was launched on October 2, 1975 to take this directive forward. The scheme, which is still in operation, is one of the world’s largest community based programmes. Its beneficiaries include children up to the age of 6 and pregnant and lactating mothers. The aim of the scheme is to improve the health, nutrition and education of the beneficiaries. Thereafter, the National Food Security Act (NFSA) 2013 was put in place to provide “food and nutritional security…by ensuring access to adequate quantity of quality food at affordable prices…” (Jamuda 2019). India’s steady march towards achieving food and nutrition security continues with the launch of POSHAN Abhiyaan or National Nutrition Mission (NNM) in March, 2018. The Abhiyaan will synergise governmental bodies and key sectors of the economy, resulting in reshaping the nutritional landscape of India. POSHAN Abhiyaan aims to reduce stunting (height-to-age ratio) by 2 per cent each year, under-nutrition by 2 per cent per year, anaemia in young children, women and adolescent girls by 3 per cent per year and low birth weight by 2 per cent per year.
India is home to a third of the world’s stunted children. Similarly, wasting (ratio of weight-to-height), another key indicator, increased from 19.8 to 21 per cent between NFHS-3 (2005-2006) and NFHS-4 (2015-2016). As many as 53.1 per cent of Indian women between the ages of 15 and 49 are anaemic (IIPS 2017). POSHAN Abhiyaan aims to reduce stunting from 38.4 per cent in the National Family Health Survey (NFHS) 4 in 2015-2016 to 25 per cent by 2022 under its ‘Mission 25 by
The programme is focused on providing nutrition and tackling micronutrient deficiencies, that is, deficiency of essential vitamins and minerals in the critical first 1000 days of life. By doing so the scheme is helping boost the nutritional outcomes in newborns, children, adolescents, pregnant women and lactating mothers. POSHAN Abhiyaan plans to meet its targets by leveraging technology and innovation, building capacity, supporting efficient governance and enabling behavioural change (MWCD 2018).
India’s Nutrition Landscape
Anaemia in adolescent girls perpetuates the cycle of malnourishment for subsequent generations. As anaemic girls grow into adults, subsequent pregnancies not only endanger their own health by way of pre-term deliveries and high risk of maternal haemorrhages, but also put their children at a higher risk of anaemia and of being born as ‘low-birth weight’ babies—perpetuating an unending loop.
As many as 26.8 per cent of Indian women marry before turning 18 (NFHS-4). Early marriage, limited life skills, little or no education, low economic and social self-reliance, lack of nutrition-hygiene-family planning related counselling and more, trigger a cascading effect. The outcome is poorly planned families, malnutrition, and heightened challenges with larger groups of vulnerable women and children. The need for a nutrition revolution, therefore, has never been more urgent.
However, the challenge of undernutrition in India is compounded by yet another burden— 20.7 per cent women and 18.6 per cent men in India are reportedly obese or overweight (IIPS 2017). This ‘double burden of malnutrition’, therefore has an immense negative bearing on the nutritional status of India. By the year 2040, India needs to bring down its key indicators of malnutrition-stunting, wasting, undernutrition and anaemia to single digits. For this to happen, the Annual Average Rate of Reductions (AARRs) for each indicator needs to be four to five times that of the current rate (Table 1).
A life cycle approach is needed for India to achieve ‘zero’ hunger and reduce malnutrition deaths by 2040. This requires prioritising nutrition-intensive investments for the first 1000 days of life (from conception to two-years) recognising it as the first window of opportunity. The next step is prioritising interventions for enhancing nutrition for adolescent girls—the mothers of tomorrow, as they represent the second window of opportunity for making ‘nutrition for all’ a reality.
The Poshan Abhiyaan, intending to work through a digital platform has currently disseminated guidelines covering all aspects of the ICDS-CAS software implementation up to the district level. Extensive capacity building programmes and community based events (CBEs) are also being organised in Anganwadi centres and field visits are being conducted in the aspirational districts and high priority states (PIB 2019).
Deficiency of essential vitamins and minerals or ‘hidden hunger,’ is a key cause of malnutrition. NFHS-4 data reveals that only 47 per cent, or less than half, of all women in India consume dark green, leafy vegetables daily and 38 per cent consume them weekly. 45 per cent women consume pulses or beans daily and an equal percentage consume them weekly. 54 per cent women do not consume fruits even once a week and only a third consume either chicken, meat, fish, or eggs daily (Fig. 1) (NFHS-4). Inadequate dietary intake of micro nutrients by women dulls their contribution as human capital and compromises the health of the future generations.
According to NFHS-4, only 9.6 per cent of children aged 6-23 months received an adequate diet. The percentage of young children (6-8 months) introduced to complementary feeding declined from 52.7 in 2006 to 42.7 per cent in 2016. Low productivity, poor cognitive and physical development, and increased morbidity and mortality arise from micronutrient deficiencies and contribute to India’s disease burden. The annual GDP losses from low weight, poor growth of children, and micronutrient deficiencies are, on average, 11 per cent in Asia and Africa. This is greater than the loss experienced in the 2008–2010 financial crisis (Paris 2016).
Iron deficiency anaemia, for instance, affects mental and physical development and is associated with 20 per cent of maternal deaths. India has one of the highest incidences of birth defects, with more than 50 per cent ascribable to Neural Tube Defects (NTDs), despite half of all NTDs being preventable with adequate folic acid intake prior to and during early pregnancy. Other deficiencies, for instance that of vitamin D and A and zinc can be easily remedied with timely interventions. The national programme for vitamin A supplementation, initiated in the 1970, has significantly reduced clinical manifestations in young children. Currently, three major strategies with varying levels of success are being used.
Dietary diversity: This is the most sustainable, long-term approach for tackling malnutrition and micronutrient deficiency. However, the availability, accessibility and affordability of different kinds of foods for diverse diets is a challenge. Also, ensuring the knowledge of these foods and how they are suitable for different life-stages, environments, economic and social contexts, poses a serious question, especially for the poor and marginalised.
Supplementation: Government programmes for Vitamin A supplementation and iron-folic acid (IFA) supplementation for pregnant women and adolescent girls have been in operation for over five decades. However, they have exhibited sub-optimal impacts. For instance, only 23.6 per cent women consume IFA tablets during pregnancy and for women in the lowest wealth index, this figure is 13.8 per cent. Similarly, 45.2 per cent of children (6-59 months) receive Vitamin A and for children in the lowest wealth index, the figure is 37.5 per cent (MWCD 2014). Two other obstacles to nutrition supplementation programmes are diluted public accountability which inhibits access; and myths, misconceptions and limited awareness, which contribute to low compliance.
Food fortification: India, as part of its medium and long-term strategy, needs to adopt universal and mandatory food fortification along with the promotion of bio-fortification. Food fortification, a process by which vitamins and minerals are added to commonly consumed foods, offers a good opportunity to improve the micronutrient status of people without changing their food habits.
Food fortification started in 1953, with vanaspati ghee fortified with vitamin A, followed by salt iodisation in 1962 and milk fortification with vitamin A and D for three years from 1989 onwards. Rajasthan’s dairy cooperative continues to fortify low-fat milk and many units voluntarily fortify edible oil with Vitamin A and D. The low cost of fortification of staple foods—for instance wheat flour can be fortified by 8-10 paisa per kg, milk by 2.5 paisa per kg, rice by 2 rupees per kg and salt by 3-4 rupees per kg—supported by comprehensive regulation, makes it an economically viable solution for addressing malnutrition.
Mandatory fortification can multiply nutritional benefits more equitably than voluntary fortification, while ensuring compliance to food safety and quality standards. Some staple foods distributed via government-funded programmes can be fortified in accordance with the Food Safety Standards Authority of India (FSSAI) standards—for example, salt with iron and iodine; wheat flour with iron, folic acid and vitamin B12; refined oils with vitamin A and D; milk with vitamin A and D; and rice with iron and other micro-nutrients. Fortified foods supplied via public-funded programmes like the targeted Public Distribution System (PDS), benefit the most marginalised and reach at least 67 per cent of the population (Majumder 2001). Introducing food fortification in other key government funded programmes such as the ICDS supplementary nutrition programme and the Mid-Day Meal (MDM) programme can also benefit pregnant and lactating mothers, and children (6-72 months) by addressing micronutrient deficiencies.
Bio-fortification: Yet to be explored in India, bio-fortification brings into focus the critical role agriculture can play in uplifting the nutritional status. Figure 2 emphasises the role of agriculture in boosting nutritional levels in the household, by encouraging production of nutrient-rich foods and taking into account seasonality, affordability, availability, demand and other key factors.
Inculcating dietary diversity for better nutrition with sustainable agriculture will also help promote women smallholder farmers. There is a deficit in maternal diet and complementary feeding for infants in India. The complementary feeding for a child between six and 24 months is less than 10 per cent. The agri-nutrition focus will ensure that mother and child have access to a diversified diet, leading to a sustainable solution. Along with the promotion of diet diversity, interventions have to be made to address the food value chain from farm to finger. Quality assurance and quality control mechanisms along the value chain should be patronised so that pregnant and lactating mother as well as the children have access to safe and nutritious food. Promotion of dryland agriculture and nutritious cereals is also necessary. Naturally biofortified crops like minor millets, Indian gooseberry (amla), drumsticks, spinach etc. can increase dietary diversity and address micronutrient deficiencies.
Given the wide prevalence of malnutrition in India, micronutrient malnutrition in particular, supplementation and promotion of dietary diversity, coupled with regulated food fortification of staples and robust public distribution mechanisms, provide solutions that will benefit the masses.
However, policy action must form the cornerstone for addressing malnutrition. It is, therefore, essential for policy makers to align the national and state goals with the UN Sustainable Development Goals. Strengthening the country’s regulatory system to improve food safety standards and better convergence of agricultural and public health strategies is extremely important. A proposed Agri-Nutrition Convergence Action Plan can encourage cohesive action by relevant ministries and departments and be pivotal to understanding the needs of producers and consumers and responding to their demands for healthier, more nutritious food.
India currently ranks 114 out of 132 countries in terms of levels of stunting in children. With India emerging as an economic superpower in the 21st century, these figures are indeed alarming and a cause for dismay. In order to achieve ‘malnutrition-free’ status, India’s development agenda needs a much stronger focus on nutrition that can be achieved by evidence-based action and by making informed choices regarding food