Nutritional well-being is central for the achievement of several national and international development goals (WHO 2016; NITI Aayog 2017). Improved nutrition is instrumental in improvements in other social objectives as well as improved cognitive ability. While India has achieved some success in income poverty reduction, the massive and unremitting burden of malnutrition is a challenging reality. The overall reduction in malnutrition has been very slow.
The country ranked 94 among 107 nations in the Global Hunger Index 2020. According to the report, 14 per cent of Indian’s population is malnourished. However, in the words of Amartya Sen: “In the avoidance of endemic undernourishment and hunger, India has done worse than nearly every country in the world.” Among the nutritional outcome measures, anthropometric measures (WHO’s method) are considered to have an advantage over others since body measurements are sensitive to even minor levels of malnutrition. Anthropometric measures, weight-for-age (underweight), height-for-age (stunted) and weight-for-height (wasted) are used to measure nutritional deprivation among children.
‘Wasting’ is an indicator of acute stage of malnutrition as well as a predictor of child mortality and morbidity. ‘Stunting’ in childhood indicates chronic malnutrition. It has been a concern and is associated with poorer educational and economic outcomes. Stunted children suffer reduction in IQ by as many as 15 points, significantly affecting schooling and education, and increasing risks of drop-out. It is well known that stunting promotes an intergenerational propagation of malnutrition. Moreover, it contributes to higher chances of maternal and neonatal mortality by creating difficulties during labour and delivery.
A child is ‘underweight’ if s/he is in the bottom 5th percentile for weight compared to their height. It is not only classified compared to other children of that age, but to their height as we clinically look for a child to be proportionate. It is a composite measure of both chronic (stunting) and acute (wasting) malnutrition. Usually, children born prematurely are often underweight. Malnutrition occurs at all stages. Malnutrition among women or adolescent girls and children is a cause of grave concern. Malnourished women or adolescent girls give birth to babies that are born stunted and thin. In this way, undernutrition is handed down from one generation to another as a terrifying inheritance.
These children fail to experience much catch-up growth in subsequent years. They are likely to get sick, they enter school late, they do not learn well, and they are less productive as adults. Moreover, stunting , along with low birth weight (LBW), is a risk factor for adult chronic disease. Increasing evidence points to the fetal and early childhood origins of adult chronic diseases. The famous Barker Hypothesis posits that maternal dietary imbalances at critical periods of development of the womb can trigger an adaptive redistribution of fetal resources (including growth retardation). Such adaptations affect fetal structure and metabolism in ways that predispose the individual to later cardiovascular and endocrine diseases.
The correlation between LBW or early childhood stunting and cardiovascular and diabetes may arise from the fact that nutritional deprivation in utero or in early childhood programmes a newborn for a life of scarcity. The problems arise when the child’s system is later confronted by a world of plenty. Persons suffering from childhood malnutrition are more likely to be afflicted by diet-related diseases (that were formerly thought to be associated with increasing affluence) such as diabetes, CVD and hypertension. Malnutrition has an irreversible effect on health and human development.
The first ‘Golden 1000 Days’ of a child’s life ~ the time between conception and a child’s second birthday ~ are a unique period of opportunity when the foundations of optimum health, growth, and neurodevelopment across the lifespan is established. During the period, under proper nutrition, children’s brains can form 1000 neural connections every seco-nd. A three-year-old’s brain is twice as active as that of an adult and the connections the brain makes are the building blocks of the future. The first 2000 days (from conception to age 5) are also a critical time for physical, cognitive, social and emotional health.
What happens in the first 2000 days of life has been shown to have an impact throughout life. Given its intrinsic and instrumental relevance, the Union and state governments in India have launched important nutrition-specific programmes starting from the Balwadi Nutrition Programme (BNP) in 1970, the massive ICDS in the late 1970s and the Mid-day Meal Scheme (MDMS) in 1995. Beneficiaries of the ICDS programme are children in the age group of 0-6, pregnant women and lactating mothers. It is the largest outreach programme operational through Anganwadi Centres (AWC) that serve as first outpost for health, nutrition and early learning services at the village level.
In 2018, the Government of India launched a flagship scheme, POSHAN (Prime Minister’s Overarching Scheme for Holistic Nutrition) Abhiyaan, with an aim to direct the country’s attention towards malnutrition of children, pregnant women and lactating mothers and to address it in a mission-mode. Despite several programmes and schemes, India’s performance towards reducing child malnutrition has failed in the last half decade. One of the startling revelations of the recent National Family Health Survey (NFHS) 5 for the year 2019-20 released by the Ministry of Health and Family Welfare shows that several states in the country have either witnessed meagre improvements or sustained reversals on child (under 5 years) malnutrition parameters such as stunting, wasting, underweight and mortality rate.
Sixteen states recorded an increase in underweight and severely wasted under-5 children among 22 states that were surveyed during the first phase of the NFHS report. Similarly, 13 states and UTs of the 22 surveyed registered a surge in the percentage of stunted children under five in comparison to NFHS–4 (2015-16). Instead of getting the wasting parameter down, states such as Telangana, Kerala, Bihar and Assam as well as the UT of J&K have witnessed an increase. States like Maharashtra and West Bengal have remained stagnant. When it comes to the proportion of underweight children, big states like Gujarat, Maharashtra, West Bengal, Telangana, Assam and Kerala have seen an increase.
What’s worse is the fact that the reversal in the downward trend has happened in child stunting. As mentioned above, stunting reflects chronic undernutrition. More than any other factor, it is likely to have longlasting adverse effects on the cognitive and physical development of a child. Sates like Telangana, Gujarat, Kerala, Maharashtra, and West Bengal saw increased levels of child stunting. Stunting is when a child has a low height for its age. It is different from wasting. If stunting is low height for a child’s weight, wasting is low weight for a child’s height. Indeed, the average height of a population’s children is increasingly recognised as an important measure of human development.
This is because the distribution of height in a population is shaped by the health and well-being that children experience at young ages. Early life is an important time; what happens to babies and children matters for their achievement, health, and survival throughout their lives. A stunted child may have a poorer immune system, brain functions and organ development. Performing below average in these areas may also limit future productivity and threaten the health of their children. Stunted children may never reach their full cognitive potential, which can lead to a lower IQ and impaired brain development. This also affects socio-emotional skills and overall health.
A study conducted by Dean Spears has also shown that taller children perform better on average on tests of cognitive achievement, in part because of difference in early-life health and net nutrition. Indian children are unhealthily short, on average. The average child in India is shorter than children raised by upper-middle class families; shorter than in other developing countries and is much shorter than would be achievable with better health, nutrition, sanitation and maternal well-being. It is a challenging reality in India. At the national level, a third of stunted children come from the richest families.
Despite rapid economic growth, it is India’s shame that Indian children are on an average shorter not only than children of the poorer and mortality stricken sub-Saharan African (SSA) countries, they are among the shortest in the world. This astonishing reality is the ‘Asian enigma’, one that can hardly be explained in terms of genetic differences. In the words of Amartya Sen: “This is India’s defective development.” Poor sanitation has a direct impact on the high rate of stunted children in India. Experts have ascribed this puzzle to the consequences of widespread open defecation (OD).
An analysis of as many as 140 demographic and health surveys, conducted by Dean Spears, revealed that the height of Indian children corelates with their and their neighbors’ access to toilets, and that OD accounts for much of the stunting in India. It is much less common in sub-Saharan Africa, China and Bangladesh. There is no simple solution for preventing stunting. However, focusing on what is commonly referred to as the first 1000 days is a key opportunity to ensure the healthy development of children. Improving education among women, encouraging a diversified diet and providing easier access to health care are some of the ways in which India can achieve nutrition security by 2030.
As Sen says: “It is not easy to think of any social problems in the contemporary world that deserves greater attention than the foggy adversity of chronic and widespread undernutrition.”
(The writer is a retired IAS officer)