India’s high malnutrition burden is a cause of concern at the highest levels. The country’s malnutrition rates are two to seven times higher than those in other BRICS nations, and the rate of decline has been far from satisfactory. The good news is that there appears to be a serious commitment and urgency to address this long-standing challenge: a national nutrition mission is being prepared and several states have initiated nutrition missions.
It is therefore timely to look at the full set of factors that determine nutrition to ensure that the measures we now undertake address them comprehensively so that they have the much-needed impact.
Child undernutrition is measured using three different indicators — stunting (too short for age), underweight (too little weighat for age), and wasting (too thin for height). Each indicator reflects a different facet of undernutrition: stunting reflects chronic undernutrition, underweight reflects a combination of chronic and immediate undernutrition, and wasting reflects acute undernutrition.
Most often, undernutrition sets in during the first thousand days of a child’s life — from conception to two years of age. If appropriate interventions are not undertaken during this critical window of opportunity, the long-term consequences are substantial.
Stunting in early life causes irreversible damage that has lifelong consequences for the child, the family and the country. It not only leads to shorter height in adulthood but also impairs brain and cognitive development, leading to poorer school performance and reduced earning potential in later life. It is estimated that stunting leads to a 4.6 cm loss of height in adolescence, a 7-month delay in schooling and 0.7 grades loss, about 10 per cent reduction in lifetime earnings, and a 2-3 loss of GDP.
Stunting also increases the risk of developing chronic diseases in adulthood such as diabetes, hypertension and heart disease, reducing productivity and increasing the costs of health care. These nibble into the quality of India’s human resources and compromise the country’s efforts to boost economic growth.
Since childhood stunting is one of the best predictors of future human capital, it is imperative to measure and track it, and institute measures with the potential to dramatically reduce it, if the country and its people are to realise their full economic and human potential.
Contrary to the popular notion that Indian children are shorter than their counterparts elsewhere due to their genetic make-up, there is strong evidence that while genetics plays a small role, all children have the potential to grow along a similar trajectory if they are fed as recommended, given appropriate care and a hygienic environment to live in, and receive timely health care to prevent and treat infections.
New analysis shows that Indian children in the critical age group of six months to two years who received feeding, health care and improved water and sanitation in adequate measure have drastically lower rates of stunting than those who received none of these adequately (23 per cent versus 52 per cent). This association is robust and holds true across both rural and urban areas and across wealth quintiles,as well asin states with poor nutrition outcomesand in districts with the poorest human development indicators.
Sadly, less than two per cent of India’s children in the critical age group have all three determinants in sufficient measure, and an unacceptably large proportion of them (63 per cent) get none of them to the recommended degree. Surprisingly, even amongst the wealthiest Indians, only about seven per cent of children receive all three categories of determinants adequately.
Clearly, stunting is not a problem of the poor alone. Undernutrition pervades all strata of society. Even children from middle and upper income households display stunting levels that are quite significant — about 50 and 25 per cent respectively.
Therefore to make a dent on undernutrition, it is critical to ensure thathouseholds and mothersacross the country adopt appropriate child feeding practices, mothers and young children get the necessary health care they need, and all have access to safe water and sanitation.
Quick and significant wins for middle and upper income populations, where access to the three determinants is not a key constraint, could be achieved through effective and sustained information campaigns that provide much needed information. To support the needs of poorer households, however, larger and more intensive efforts will be needed.
These segments of the population will need the full set of interventions that begin with mothers before birth and continue through the first two years of a child’s life. Measures that ensure health and good nutrition for mothers — such as delaying the age of marriage and child birth and providing pregnant women with adequate antenatal care and dietary intake, including iron supplementation, will need to be complemented with the full set of interventions for the child. These include breastfeeding, appropriate complementary feeding practices, and the provision of micronutrients, together with timely immunisation, treatment of infections and appropriate feeding during illnesses,as well as access to safe water, sanitation and hygiene.
In sum, isolated interventions will be inadequate to address a challenge of this magnitude. Fortunately, programmes to address all the critical determinants of nutrition exist and are being strengthened: the Integrated Child Development Services scheme has been restructured; a National Nutrition Mission is being developed. The National Health Mission, which seeks to deliver the full set of health interventions to pregnant women and children, is up and running; and the Swacchh Bharat Mission that seeks to make habitations ‘open defecation free’ and provide safe drinking water is underway. The synergies between these programmes must now be fully exploited.
The potential to reduce stunting substantially in a few years’ time has been demonstrated. Besides countries such as Peru, Rwanda, and Nepal, India’s own state of Maharashtra stands out in this regard. Maharashtra achieved a reduction in stunting in children under two years of age from 39 per cent in 2005-06 to 23 per cent in 2012.
India must now seize the opportunity nationally and ensure that every child receives its birthright — the opportunity to lead a healthy and fulfilling life that enables each to attain her full potential.