Why we need to focus on nutrition, not hunger

In common parlance, hunger and nutrition are two different things. Hunger is associated with food shortages and starvation. It produces images of emaciated people holding empty food bowls. GHI uses nutrition and infant mortality indicators. But it is preamble states that “communities, civil society organizations, smallholders, 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 per capita intake of cereals, vegetables and milk has multiplied. Therefore, it is controversial and unacceptable to associate India with countries facing severe 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, remains a problem. Unlike the GHI, the National Family Health Survey (NFHS) does a good job of providing comparative data at the state level, including leading indicators 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 disproportionately affect preschool-age children (under 6 years of age) and compromise the child’s physical and mental development, while increasing vulnerability to infection. Furthermore, undernourished mothers (attributable to social and cultural practices) give birth to low birth weight babies who remain susceptible to infections, carrying their deficiencies into childhood and adolescence.

The jury is divided on causes and solutions. Leela Visaria, a leading sociologist, links the nutritional status of young children with the post-neonatal phase when children suffer from acute respiratory infections and diarrheal diseases. Sanitation and hygiene require a lot more work, she says. Director of the Nutrition Foundation of India, Prema Ramachandran, says: “Body Mass Index testing is the best way to identify overweight and thin children and the ongoing Poshan Abhiyaan provides for this.” Professor V Subramanian of the Harvard Chan School of Public Health writes: “Current approaches to childhood malnutrition need to be disentangled 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, however simple and cheap they may seem, need to go deeper into individual households. The first challenge of child nutrition is related to breastfeeding. The WHO and UNICEF recommend that breastfeeding should be started within the first hour of birth and babies should be exclusively breastfed for the first six months. According to NFHS 5, in India, the percentage improvement for children who were exclusively breastfed when they were less than six months old increased from 55% in NFHS 4 to 64% in NFHS 5. That’s progress, but it’s not enough. By not being breastfed, the baby is denied the benefits of acquiring antibodies against infections, allergies, and even protection against various chronic conditions. NFHS says that only 42 percent of babies 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 percent, while those below 50 percent include Bihar, Punjab, Kerala, Tamil Nadu. and West Bengal. The others are in the middle.

The second theme relates to the feeding practices of young children. The root is generalized practices such as not introducing semi-solid foods after six months, prolonging breastfeeding well beyond the recommended six months and giving foods that lack nutritional diversity. NFHS 5 shows that the improvement has been marginal in the last two reports and surprisingly states like Maharashtra, Rajasthan, Assam, UP and Gujarat are at the bottom.

Comments from CHETNA, a 40-year-old NGO (with which the author is associated), working for the health and nutrition of women and children in three states (Gujarat, Madhya Pradesh and Rajasthan) are revealing. The NGO echoes the findings on breastfeeding and young child feeding practices, not through surveys, but by looking at what happens within households. 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 grains when they need energy and nutrient-rich food to develop. Even a teaspoon of ghee or oil added to semi-solid dal or khichri can provide adequate protein and calories, but this is ignored by mothers. Likewise, diversity in the diet is important. Families start gardens and some even raise poultry once they are taught how nutrition can be improved.

The third problem is the result of poor nutrition. According to NFHS 5, the percentage of children who are stunted, wasted, and underweight is 36%, 19%, and 32%, respectively. It is worrying 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 with anemia: from 59% in NFHS 4 to 67% in NFHS 5. This has a lot to do with the misconception that manufactured snacks are “good food.” . Anecdotally, there are reports that households in Dharavi, Asia’s largest slum, spend up to 30 rupees a day on packaged snacks like chips, papad and other overly salty edibles. Parents allow the child to sleep on a malnourished (virtually empty) stomach. CHETNA found the same phenomenon in urban slums and villages and lamented that the same Rs 5 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 lately, but most of the beneficiaries of these food distribution programs are children attending anganwadis or schools, adolescents, and pregnant and lactating mothers. This must continue, but newborns, infants and young children need care too. Weight control is an indicator, not a solution. India has successfully overcome much bigger problems: reduced maternal and child mortality, better access to sanitation, clean drinking water, and clean cooking fuel. We should not waste any more time with the GHI ratings, which are distorted and irrelevant. Instead, states should be urged to examine the NFHS findings to take a new direction in improving poshan practices for the youngest and most vulnerable sections of society: helping mothers improve the lives of their babies and young children within the household by measuring and demonstrating how much diet, food intake and parenting practices matter.

The writer is a former secretary of the Ministry of Health.