Although Covid-19 has reduced the hustle-bustle of ongoing festivities, it has not and should not dampen our zeal to celebrate and our intent to derive happiness being with our loved ones either in person or in-spirit. Work is workship for many; thus on the eve of Dusshheraa, a festival to celebrate the victory of good over evil, strengths over weaknesses, I propose an analogous idea for our own field of public health and nutrition (PHN).
As reported by the Global Nutrition Report 2020, “India is off course to meet the global targets for all indicators analysed with adequate data”. Just last week, most newspapers were highlighting the poor ranking of India (94/107) in the Global Hunger Index. In fact a lot of indicators related to nutrition security in India and overall health of our citizens unfortunately represent huge PHN burden in a variety of forms, some of which are discussed as below. According to the same report, the national prevalence of under-five stunting is 37.9%, which is substantially higher than their developing country average of 25%. Further, India's under-five wasting prevalence of 20.8% is also greater than the developing country average of 8.9%. In India, 54.9% of infants under 6 months are exclusively breastfed. More than half of our women of reproductive age have anaemia. The purpose of discussing these is not to lament over the issue but use collective wisdom and concerted efforts to feel inspired and defeat this malnutrition demon much like the ten headed Ravana this D-U-S-S-H-H-E-R-A-A. I have also highlighted some small strategic steps that could help close the gap and help us reap the benefits sooner than later.
D- Poor Diet Quality especially dietary diversity.
20% of Indian kids 6-23 month olds do not eat from the minimum of 5-8 food groups as per the State of World’s Children report 2019 by UNICEF. In fact 56% of South Asian kids are not fed fruits and vegetables at all. Research from cohort studies shows that carbohydrate rich diets (and that too refined or simple carbohydrates exacerbated by high trans fats, added sugar and salt) over long periods of time without other key macro- and micro-nutrients will fuel metabolic diseases. Breastfeeding and poor IYCF are key reasons for a disadvantaged start to most kids in our country. How should we then aspire to attain high intellect to drive country’s productivity and national economic growth? Thus making healthy diets accessible and affordable to all should be the foremost priority for our policy makers and all stakeholders. Nutri-gardens or poshanvatikas are being promoted under Poshan Abhiyaan to improve diet diversity at low costs.
U – Undernutrition needs to be defeated urgently
Undernutrition is a collective term used to indicate the stunting, wasting and underweight burden among our children. In 2017, of the 10 lakh children that died in India, malnutrition was the attributable cause for 70% of them (7 lakhs). We have been carrying this huge burden for far too long. Yes it is complex but then it does not mean that complex problems lack solutions. Multiple pieces of work by leading organizations working in this space like the International Food Policy Research Institute (IFPRI) have shown that if we increase the coverage of even ten essential services (like breastfeeding, food supplementation, counseling on complementary feeding, vitamin A supplementation, pediatric IFA supplementationand growth monitoring/screening for severe acute malnutritionetc), it will translate in to huge benefits in reducing this heavy weight problem holistically.
S – Support SustainableClimate smart agriculture techniques
The food security challenge will only become more difficult, as the world will need to produce about 70% more food by 2050 to feed an estimated 9 billion people. This challenge will be intensified by agriculture’s extreme vulnerability to climate change. Agriculture is a major part of the climate problem, contributing 19–29% of total greenhouse gas (GHG) emissions. Additionally, 1/3 of food produced globally is either lost or wasted. The World Bank opines that investment in climate-smart agriculture (CSA), an integrated approach to managing landscapes—cropland, livestock, forests and fisheries—may help address the interlinked challenges of food security and accelerating climate change. An example is the Bank funded Maharashtra Project for Climate Resilient Agriculture estimated to yield climate change improvements of US$386 million using improved irrigation and drainage technologies.Addressing food loss and waste will also be critical to helping meet climate goals and reduce stress on the environment.
S - Strengthen surveillance and capacity to forward the PHN agenda in our country.
Capacity building to deliver PHN needs augmentation and incorporation of technology to help build skills faster and in a scalable manner. Use of ICDS-CAS by the Ministry of Women and Child Development under our Poshan Abhiyaan is one such example. Our frontline workers need innovative ways to reduce the burden and to invigorate their motivation to make a difference in the indicators at the ground zero level.We must build in surveillance mechanisms, such as improved monitoring and operations research, to assess and track the progress.
H- Hunger and Hidden hunger- Anemia among women and children
The double whammy of not having enough quantity to eat coupled with poor quality of diets for large sections of our population is heart-wrenching. It is estimated that more than two billion people suffer from ‘hidden hunger’ (micronutrient malnutrition) globally, with nearly half living in India. Results from a recent study (Ref: https://www.frontiersin.org/articles/10.3389/fsufs.2018.00011/full) suggest that more than 80% of our population is at the risk of deficiencies in calcium, vitamin A, B12, folate etc. And among a quarter of these, iron, zinc, and vitamin B6levels are also grossly sub-optimal. The authors suggest that “these deficiencies are the result of a combination of a monotonous cereal-dominated diet lacking in diversity, and overall insufficient food intake.” Many experts opine that developing robust, resilient and equitable food system may help deliver basic nutritional requirements to majority of our people. Measures like bio-fortification etc have been proposed too.
H-Harmonize multi-sectoral policies pushing for convergent action
54% of children in India are either stunted, wasted or overweight as per the latest State of World’s Children 2019 UNICEF report. A holistic approach to tackling multiple forms of malnutrition is preferred than siloed efforts. In this regard, investing insimultaneous efforts to address the underlying determinants of malnutrition,such as poverty, food insecurity, education, poor sanitation and hygiene, environment quality etc will be essential to support the benefits of the nutritioninterventions.
E- Equity in our policies
The 2020 Left Out and Left BehindCARE’s gender report highlighted that women and girls are the majority of food producers and food providers for their households, but their contributions are frequently unseen. In fact women lack the access, information, and inputs they need to fight food insecurity and malnutrition.“Too often, women eat last and least”, they say! The report attributed the existing flaws in food systems to gender inequalities and the unfair treatment of women and girls. Rising hunger and food shortages are also putting additional burdens on women, from mental health risks to gender-based violence. Thus “addressing gender inequalities will help deconstruct the barriers these women face, boosting productivity, promoting good nutrition, and leading to better outcomes for women, girls, and their communities.” I feel that India’sBetiBachao, Betipadhao (Save the girl child and educate her) needs to be further bolstered and should be transformed to BetiBachao, Betipadhao, Betikoachhakhilao, tandrustbanao (Feed the girl child well and make her healthy).
R -Regulate the food industry and conflict of interest
The government must step up their presence and action to regulate markets especially to downsize and/or eliminate the unethical practices by private players and food industry. For eg. misleadingrepetitive and targeted advertisements, sponsored research to confuse masses, corruption etc. The World cancer Research Fund 2019 report notes some of the common tactics used by industry as delay, divide, deflect and deny. This a worldwide phenomenon and must be strictly regulated by governments in the interest of PHN. There are a few good initiatives by the industry too and they must be celebrated and acknowledged to promote positive behavior. The use of CSR to educate or sponsor meals for poor, spread awareness about WASH, support talent hunts and provide opportunities to deserving candidates from marginalized communities etc must be reinforced. We need the industry to be our additional vehicles of delivery and outreach to ensure better health and nutrition among all especially the vulnerable populations.
A -Adequate nutrition across life course
Nutrition from womb to tomb is critical to healthy and productive lives. India has a plethora of programs for PHN to support most critical windows of growth and development. However, social security and safety nets need to be substantially high quality and forward thinking. Quality of meals should be enhanced, inclusion of better proteins and fruits, green vegetables to our vulnerable populations must be a priority for the nation. Providing integrated interventions for early childhood development must be seen a critical step to improving quality of lives and productivity. When COVID struck, a lot of our social safety nets were jolted resulting in patchy coverage and unprepared sub-optimal delivery of even the minimum expected services. This pandemic-induced interruptions to health, nutrition, and social protection services were estimated to be about 30% by UNICEF in many areas and even stopped completely under some lockdowns. Although social protection programs, including cash and food transfers, were proposed by Government of India (PM’s Garib Kalyan RojgarYojna etc, they are struggling to meet the skyrocketing demand resulting from job and income losses.
A - Arrestoverweight-obesity and related risk factors for metabolic diseases
The Comprehensive National Nutrition Survey (CNNS)documented 5% hypertension, 10% pre diabetes among our young children and adolescents (5-19 y). In addition overweight obesity across all states is rising at unprecedented rates. Please note that obesity has risen 10-12 fold from 1975 to now in India. Again ensuing sedentary lifestyles coupled with access to cheap calories, high in poor quality fat, sugar and salt are a main reason for this rise in overweight obesity pandemic in India. In addition poor awareness about the long term harms of obesity, lack of policy support and financial challenges (healthy diets being at least 5 times more expensive) are some of the reasons fueling the obesity burden in India.
In summary, reflection on these 10 modifiable risk factors or problem areas in PHN may help think through some innovative local solutions too. Thus this Vijaydashmi let us collectively renew our pledge to fight off these 10 headed demons of poor public health and nutrition in India. Like we enjoy contributing in the effigy burning, celebrate the rise of goodness symbolically, all stakeholders must accelerate the removal of malnutrition related vices from our country in order to see our masses truly reap the benefits of a Swastha Suposhit Swachh Bharat. Happy healthy Dusshheraa everyone!
(Views are personal)
(The author is the head, Nutrition Research and Additional Professor with Public Health Foundation of India)
