Each October, the world hunger index (GHI) is released. This usually creates an uproar, and for good reason. But this time it went too far. The source is a 16-year-old German and Irish organization, which measures and ranks countries on a Hunger Index at global, regional and national levels, but not at the sub-national level where some Indian states fare better. The stated goal of the GHI is to reduce world hunger. But its methodology focuses disproportionately on under-fives.
In common parlance, hunger and nutrition are two different things. Hunger is associated with food shortage and starvation. It produces images of emaciated people holding empty food bowls. The GHI uses infant mortality and nutrition indicators. But its preamble states that “communities, civil society organizations, small producers, farmers and indigenous groups…shape how access to nutritious food is governed”. This suggests that GHI sees hunger as a challenge to food production when, according to the FAO, India is the world’s largest producer and consumer of cereals and the largest producer of milk; when the consumption of cereals, vegetables and milk per capita increased considerably. It is therefore controversial and unacceptable to associate India with countries facing severe food shortages, which GHI has done.
The sensational use of the word hunger is abhorrent given the facts. But it is undeniable that in India, nutrition, especially 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 key indicators that determine health and nutrition. The 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 under the age of 6) disproportionately and compromise the child’s physical and mental development while increasing susceptibility to infections. Additionally, undernourished mothers (due to social and cultural practices) give birth to low birth weight babies who remain susceptible to infection, carrying their disabilities into childhood and adolescence.
The jury is divided on causes and solutions. Leela Visaria, a renowned sociologist, links the nutritional status of young children to the post-neonatal phase when children suffer from acute respiratory infections and diarrheal diseases. Sanitation and hygiene take a lot more work, she says. Director of the Nutrition Foundation of India, Prema Ramachandran said, “Body Mass Index testing is the best way to identify thin and overweight children and the ongoing Poshan Abhiyaan is considering it.” Professor V Subramanian of the Harvard Chan School of Public Health writes: “There is a need to de-clutter current approaches to child undernutrition by keeping them simple. I advise against a disproportionate focus on anthropometry (body measurements); instead, the need is to have direct engagement with actual diet and food intake.
The irony is that nutrition-related problems and their solutions, although they seem simple and cheap, need to be explored in individual homes. The first nutritional challenge of the child concerns breastfeeding. WHO and UNICEF recommend that breastfeeding be initiated within the first hour of birth and that infants be exclusively breastfed for the first six months. According to NFHS 5, in India, the percentage improvement of children who were exclusively breastfed before six months increased from 55% in NFHS 4 to 64% in NFHS 5. This 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 diseases. According to the NFHS, only 42% of infants are breastfed within one hour of birth, which is the recommended standard. Interestingly, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha and Maharashtra, Manipur, Rajasthan, Himachal Pradesh and Haryana score above 70%, while those below 50% include Bihar, Punjab, Kerala, Tamil Nadu and West Bengal. The others are in between.
The second problem relates to the feeding practices of young children. At the root are widespread practices such as not introducing semi-solid foods after six months, prolonging breastfeeding well beyond the recommended six months, and feeding foods lacking in nutritional diversity. NFHS 5 shows that the improvement has been marginal over the past two reports and surprisingly states like Maharashtra, Rajasthan, Assam, UP and Gujarat are at the bottom of the pack.
The feedback from a 40-year-old NGO CHETNA (with which the author is associated), which works for the health and nutrition of women and children in three states (Gujarat, Madhya Pradesh and Rajasthan) is revealing. The NGO echoes the findings on breastfeeding and young child feeding practices, not through surveys, but by observing what happens within homes. Young children are allowed to run around while eating, exposing the food to flies, dust and heat. The NGO has also found that children are weaned on a watery liquid from cooked cereals when they need energy- and nutrient-dense foods to thrive. Even a teaspoon of ghee or oil added to semi-solid dal or khichri can provide adequate protein and calories, but mothers ignore it. Likewise, dietary diversity is important. Families are starting vegetable gardens and some are even raising poultry once they have been taught how to improve nutrition.
The third problem is the result of poor nutrition. According to NFHS 5, the percentage of children who are stunted, wasted, and underweight are 36%, 19%, and 32%, respectively. It is worrying that states like Bihar, UP and Jharkhand fell from their own levels five years ago. Overall, there was an eight percentage point increase in children with anemia – from 59% in NFHS 4 to 67% in NFHS 5. This has a lot to do with the misguided belief that snacks manufactured are “good foods”. Anecdotally, reports indicate that households in Dharavi, Asia’s largest slum, spend up to Rs 30 a day on packaged snacks like crisps, papad and other overly salty edibles. Parents allow the child to sleep on an undernourished (almost empty) stomach. CHETNA saw the same phenomenon in urban slums and villages and lamented that the same 5 rupees spent on manufactured snacks would be better spent on buying an egg.
Nearly a dozen nutrition programs have been implemented since 1975. Several more have been added recently, but most of the beneficiaries of these food distribution programs are children attending anganwadis or schools, adolescents and mothers pregnant and breastfeeding. This must continue, but newborns, infants and toddlers also need attention. Weight monitoring is an indicator, not a solution. India has managed to overcome much bigger problems – reducing maternal and child mortality, improving access to sanitation, clean water and clean cooking fuel. No more wasting time on GHI rankings, which are skewed and irrelevant. Instead, states should be urged to consider the findings of the NFHS to guide a new path to improve poshan practices for the youngest and most vulnerable sections of society: helping mothers improve lives of their infants and toddlers at home by measuring and demonstrating how important diet, food intake and parenting practices are.
The writer is a former secretary at the Ministry of Health
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