India is home to one-third of stunted children in the world. Anaemia and micronutrient deficiency is all pervasive. Along with undernutrition, 20.7 per cent women, and 18.6 per cent men are obese and overweight, shows the National Family Health Survey IV, 2016 (NFHS-IV). India runs the risk of an impending nutrition famine and epidemic of obesity, diabetes and other non-communicable diseases (NCDs) related to poor nutrition. Non-communicable diseases, including heart disease, stroke, cancer, diabetes, and chronic lung disease, are collectively responsible for almost 70 per cent of all deaths worldwide, according to the World Health Organization. The hunger and the double burden on malnutrition indicates a broken food system, leading to consumption of unsafe diets, which needs urgent attention. The vulnerability to life and livelihoods are further compounded by increasing use of tobacco, and rise of sugar level in blood among men and women. Around 6.8 per cent women and 44.5 per cent men in the 15-49 age group use tobacco (NFHS-IV). Given the double burden on malnutrition, unhealthy diets, exponential jump in cardio vascular diseases, India has become the diabetes capital of the world. An emergent action is needed to fix it.
Fighting Malnutrition In An Indian Way
India has gone past the days, when food security alone was the single most worrying factor. Hunger reduction was the first priority through maximising food production, and establishing public distribution system for making it easily accessible and available to the masses. However, food security, especially through excessive focus on higher production of cereals, was unable to provide guarantee to health and cognitive wellbeing. For better health and cognitive skills, the country needed to put equal focus on dousing invisible hunger. Consumption of food having adequate micronutrient and minerals and timely initiation and continuation of certain foods among children are some of the basic elements of addressing the nutritional requirements of the body. Eating adequate is not enough. Eating right is essential. The successive rounds of the NFHS have demonstrated the slow growth in reversing the malnutrition trajectory of the country. The problem is huge and now it is not just undernutrition, it is also the excess of it in the form overweight and obesity, that has affected the lives of millions in this country. It requires a revolution to reverse the nutrition famine using India’s gold mines of models, in-country wisdom and knowledge, in which the deficiency of micronutrients has assumed epic proportion in the country.
However, for a nutrition revolution to succeed, we need to address India’s double burden on malnutrition: the abnormally high degree of undernutrition in one hand and increasing proportion of overweight and obesity on the other.
As India gives a major push to its fight against malnutrition through the Poshan Abhiyaan, it is imperative that the programmes that are already in place for addressing nutrition and food-related issues are integrated, and the existing infrastructure and processes are scaled up. Poshan Abhiyaan in its current form addresses undernutrition and anaemia. Poshan Abhiyaan after a very successful rollout in the country need to prioritise actions to address obesity and overweight and micronutrient malnutrition in a comprehensive manner.
India has numerous states that have shown the way in using home grown and homemade safe and nutritious foods for substantial reduction in anaemia, stunting and wasting. Also, each Anganwadi Centre can become a centre of rich practices and learnings—for scaling up and replication. It is all about fighting malnutrition together in an Indian way, to convene and converge to trigger transformative action. In the nutrition sector, the greatest challenge is message and stakeholder alignment. This needs to be resolved. The sector needs better inter and intra departmental convergence and more and more people’s networks, strategic alliances and coalitions for better programme outcomes.
The village level platforms, like Village Health Nutrition Sanitation Day (VHNSD) needs to function excellently with support from the community, local government, health and Integrated Child Development Services (ICDS) department. The Anganwadi centre can be a Centre of Excellence with convergence of all other services. The media can play a galvanising role in the fight against malnutrition.
Key drivers for a nutrition revolution
Some of the enablers listed below will be the key drivers for the nutrition revolution, enabling convergence among all the players.
1. Data driven management and evidence-based programming: India undertakes a national nutrition and micronutrient status survey that provides reliable estimates on key parameters on nutrition and micronutrients for children, women and men at least at the district level every three years in the country. The comprehensive national micronutrient status survey would be helpful to formulate appropriate policy on food enrichment programmes such as supplementation, fortification including bio-fortification to address micronutrient malnutrition and morbidity through proper quality assurance and quality control measures and regulatory enforcements. The periodic survey and assessment is necessary, along with scaling up of the current CAS- Computer Application Software - to improve transparency and public accountability - a key factor in data driven management. Social Audit and Micro Level Planning with the involvement of local government bodies and Self Help Group platforms can be backed by high quality data and rigorous evidences. The data integrity is a key driver of success for nutrition planning and program delivery effectiveness.
2. Social Behaviour change communication with Inter-personal counselling at its core: The fight against malnutrition is majorly about bringing in more awareness - a revolution in human behaviour towards nutrition. The behaviour change strategies need to target making nutrition an ideology by every individual and households, changing narratives, and raise awareness about healthy diet and dispel myths and misconceptions. In this, intimate inter-personal counselling, with home contacts as the priority interventions will be the key to success. Maternal Infant and Young Child Feeding is a major challenge during the first one thousand days’ window. The inter-personal counselling must prioritise actions on feeding behaviour.
Women empowerment without the involvement of men is a myth and an impossible task to achieve. Therefore, social Behaviour Change Communications should also cater to and involve men and focus on changing their thinking patterns to allow females to take charge of resources and eat right in order to provide adequate nutrition to the present and future generations.
3. Knowledge assimilation and transfer across clientele including communities: The knowledge gaps need to be filled up - in order to build the nutrition narrative. India needs to bring out a National Nutrition report. In a similar manner, each state and district should bring out its own nutrition status report in regional languages for wider dissemination. India’s rich and best practices, impact models and islands of excellences need to be documented and mainstreamed through regular publication of snippets and articles in popular media for the general population.
4. Action Research projects in malnutrition and hunger hot spots: Impact oriented action research projects in aspirational districts having a target to reduce anaemia, stunting and wasting should be undertaken and any islands of excellence should be highlighted for scaling up. These research projects can provide knowledge on programme design and implementation in the country.
5. Technology, innovation and breakthrough research: New technological breakthroughs, innovations, and research happening in India and other countries in the field of Nutrition should be highlighted and adapted after validation and considering legal and cultural setting. India’s premier research bodies like AIIMS, ICMR, ICAR, CFTRI, NIN, IIPS etc. need to monitor the research, protocols, guidelines and standards so that only research and innovations with public interest orientation pass the test, and later passed on to the people after proper regulatory enforcement and monitoring.
6. Nutrition during emergency and disasters: Disasters have a significant impact on nutrition. It compounds vulnerability and every disaster has differential impact and differential recovery pattern. Many states in India are prone to disasters and emergencies. Increased climate change, soil degradation and carbon emissions from the agricultural fields, makes people more exposed and vulnerable to food and nutrition insecurity.
Food and nutrition crisis is an immediate outcome of disaster, that traps the community in a cycle of poverty and hunger. Initiatives to make agriculture more adaptive and resilient to climate variability and in the process to reducing carbon emission, addressing community mental health, and breakthrough research on climate-smart nutrition-sensitive agriculture will be key to address nutrition during disasters and emergencies. A new National Policy on Mainstreaming Sustainable Food and Nutrition Security in Disaster Risk Reduction (DRR) programmes - with focus on the first 1,000 days of life will be a key requirement.
7. A New Climate Smart and Nutrition Sensitive Agriculture Policy that decentralises agriculture geographically, focusing on dry land agriculture, integrating animal husbandry and fishery, with emphasis on coarse nutritious cereals and millets backed by technology and pricing and decentralised procurement policies is needed for a Nutrition Revolution. It is necessary to address post-harvest losses and waste, as well as non-food factors like clean drinking water and sanitation.
A food-based approach, sustainable climate-smart agriculture, bio fortification of crops to increase their nutritional value through natural ways, preserving the natural ecosystem, forest and common property for a sustainable solution to climate change and malnutrition are also necessary.
Converging campaigns, movements and food entitlement programs: Optimising outcomes
It is a feel-good factor that India is running a number of flagship programmes, campaigns and movements at the national and state level, that have a direct and indirect bearing on nutrition outcomes. The proposed Nutrition Revolution needs to build on these programmes, campaigns, and movements, and leverage the resources already invested. A cementing together of these programmes and movements can help scale up the efforts. In addition to existing campaigns and movements, there has to be specific campaigns and movements that will have bearing on revolution outcomes. Similarly, the pregnant and lactating mothers and children under six years of age are entitled to avail services from Targeted Public Distribution System(TPDS), and Integrated Child Development Service program as mandated under National Food Security Act-2013. Apart from this, there is also mid-day meal program, which can benefit children above six years of age and adolescent girls. A systematic convergence and food and nutrition planning, and improved access can meet the food and nutrition requirement of pregnant and lactating mothers by 70 per cent and for the children under six years by almost 100per cent. India needs to take advantage of these entitlements program where food is regarded as rights.
A revolution within: Nutrition, part of an ideology; a National Pride
A Nutrition Revolution would mean sustainable and responsible nutrition, with good nutrition as part of ideology and matter of national pride. A number of ethical and environmental considerations are necessary not only for sustainable nutrition, but also for a sustainable planet. The nutrition revolution needs to consider those aspects for safe food practices, sustainable use of resources, and prevent exposure of children to heavy metals which leads to behaviour disorders.
Nutrition needs to become every individual’s and household’s priority, go beyond the life cycle approach (from cradle to grave), and stretch across sectors and themes, and become the agenda of the nation as a key driver of the development engine. Good Nutrition becomes everyone’s agenda—the norm; a rule of behaviour such that individuals prefer to conform to it on condition that they believe that most people in their relevant network conform to it, and most people in their relevant network believe they ought to conform to it and may sanction deviations. There has to be improved state accountability, so that each and every individual, specifically pregnant and lactating mothers and children under two years of age, to access and consume safe and nutritious foods.
We should work towards a public interest policy and legislations, where India’s poorest citizens need not struggle for protein and vitamins and minerals to mitigate hidden hunger and even wrinkles on their skin. The movement and drive should be such that, the country witnesses an end to nutrition disruptions and that malnutrition is no longer an intra-generation cycle or a puzzle. All the skilled human resources should join hands, building on stories of good nutrition to end malnutrition. We need a responsible revolution with women at the forefront.
(This is the sixth in a series of articles on the need for a Nutrition Revolution in India.
Basanta Kumar Kar is recipient of the prestigious global ‘Transform Nutrition Champions’ award for outstanding contribution to nutrition in South Asia and the ‘Odisha Living Legend’ award for contribution to public policy. For his decades long contribution to champion the cause of sustainable food and nutrition security in India and globally, Kar is also known as the ‘Nutrition Man’. He is currently Country Director, Project Concern International/India, Contact- firstname.lastname@example.org)