Be­yond fill­ing bel­lies: Nutri­tion is about health

The cri­sis will per­sist as long as pol­i­cy­mak­ers con­tinue to view nutri­tion and food se­cu­rity in terms of sub­sis­tence and sur­vival, of fill­ing the stom­ach, and not in terms of good health or well­ness

Governance Now - - FRONT PAGE - Veena S Rao

The union cabi­net has ap­proved set­ting up of a Na­tional Nutri­tion mis­sion (NNM) with a three-year bud­get of ₹9,046.17 crore com­menc­ing from 2017-18, states a press re­lease of De­cem­ber 1, 2017. From the lim­ited in­for­ma­tion avail­able in the public domain, it ap­pears that the mis­sion is not con­cep­tu­alised as an ex­ec­u­tive kind of mis­sion, like the Na­tional Health mis­sion, with a com­pre­hen­sive strat­egy, roadmap, ob­jec­tives, need-based in­ter­ven­tions, and in­no­va­tion in ser­vice de­liv­ery. rather, its man­date ap­pears to be to mon­i­tor, su­per­vise, fix tar­gets and guide nutri­tion-re­lated in­ter­ven­tions across the min­istries; “map var­i­ous schemes con­tribut­ing to­wards ad­dress­ing mal­nu­tri­tion”, in­tro­duce ro­bust con­ver­gence mech­a­nisms, Ict­based real-time mon­i­tor­ing sys­tem, dig­i­tal­i­sa­tion of the an­gan­wadi, so­cial au­dits, nutri­tion re­source cen­tres and jan an­dolans.

This way, the NNM looks more like a mis­sion for mea­sure­ment of mal­nu­tri­tion, or some kind of an apex com­mit­tee for na­tional nutri­tion mon­i­tor­ing. No hint is given as to the method­ol­ogy, ad­di­tional man­power for the new grass­roots work, or any in­sti­tu­tional mech­a­nisms to achieve the ob­jec­tives, ex­cept that the im­ple­men­ta­tion strat­egy would be based on in­tense mon­i­tor­ing and ‘con­ver­gence ac­tion plan’ right up to the grass­roots level.

clearly, this is at wide vari­ance from what was an­nounced in the fi­nance min­is­ter’s bud­get speech on July 10, 2014, that “a na­tional pro­gramme in mis­sion mode is ur­gently re­quired to halt the de­te­ri­o­rat­ing mal­nu­tri­tion sit­u­a­tion in In­dia, as present in­ter­ven­tions are not ad­e­quate. a com­pre­hen­sive strat­egy in­clud­ing de­tailed method­ol­ogy, cost­ing, time­lines and mon­i­torable tar­gets will be put in place within six months.”

The mis­sion ap­pears to be based on the premise that no new nutri­tion or nutri­tion re­lated in­ter­ven­tions are re­quired, that there is “no dearth of schemes di­rectly/in­di­rectly af­fect­ing the nu­tri­tional sta­tus of chil­dren (0-6 years), and preg­nant and lac­tat­ing moth­ers”. Nu­tri­tional lev­els in the coun­try are high be­cause of “lack of cre­at­ing syn­ergy and linking the schemes”, and that “NNM through ro­bust con­ver­gence mech­a­nism and other com­po­nents would strive to cre­ate the syn­ergy”. It be­lieves that mal­nu­tri­tion will re­duce if tar­gets are set, and achieved through con­ver­gence, syn­ergy, real-time dig­i­tal mon­i­tor­ing and mea­sure­ment of mal­nu­tri­tion.

It is dis­ap­point­ing that the mis­sion does not even en­quire into, leave alone ad­dress, the rea­sons why im­prove­ment of our nutri­tion in­di­ca­tors across the board is so tardy. To ask a few ques­tions: Why has the pro­por­tion of un­der­weight chil­dren dropped by only 6.8% be­tween NFHS 3 and 4, when per capita in­come has al­most quadru­pled dur­ing the same pe­riod; why has wast­ing and se­vere wast­ing in­creased by around 3%? Why do more than 50% of our women and chil­dren con­tinue to be anaemic, when the na­tional nu­tri­tional anaemia pro­phy­laxis pro­gramme has been in op­er­a­tion since the 1970s?

and most dis­turb­ing is the lat­est NFHS 4 data that only 9.6% chil­dren be­tween 6-23 months (11.6% in ur­ban ar­eas and 8.8% in ru­ral ar­eas) re­ceive ad­e­quate diet. The ac­com­pa­ny­ing chart, ex­tracted from NFHS 4 Fact­sheets (2016-17), is a di­rect snap­shot of the In­te­grated child De­vel­op­ment Ser­vices (ICDS), the only scheme in our coun­try with a nutri­tion sup­ple­men­ta­tion com­po­nent for chil­dren be­low six years, which has been in op­er­a­tion for more than five decades.

ad­e­quacy of in­fant nutri­tion, whether through sup­ple­men­tary nutri­tion from the an­gan­wadi or in the house­hold, is squarely the man­date of the ICDS. at the an­gan­wadi, this in­volves the sup­ply of pro­tein calo­rie mi­cronu­tri­ent en­riched sup­ple­men­tary food, and at the house­hold it in­volves pro­vid­ing in­for­ma­tion to trig­ger be­havioural change about timely and ad­e­quate com­ple­men­tary food for in­fants. Judg­ing from the chart, the present in­ter­ven­tions have failed on both counts, re­sult­ing in loss of zil­lions of brain cells of in­fants, and pre­vent­ing them from at­tain­ing their full po­ten­tial of mus­cle and height, a bur­den car­ried for life.

and we must re­alise with due se­ri­ous­ness that this refers to our de­mo­graphic di­vided, our fu­ture work force, on whom we de­pend for fu­ture eco­nomic growth. clearly, the present in­ter­ven­tions are not work­ing, nei­ther at the an­gan­wadi, nor in the house­holds. and it is un­likely that in­ad­e­quacy in in­fants’ di­ets will be ad­dressed through dig­i­tal­i­sa­tion and tar­get set­ting. It can only be ad­dressed through ad­e­quate and timely com­ple­men­tary feed­ing, for which ex­ist­ing in­ter­ven­tions have failed, and the NNM of­fers no trans­for­ma­tional strat­egy shift or new in­ter­ven­tions.

The data men­tioned above is specif­i­cally about ad­e­quate diet of chil­dren un­der two years, and not about un­der­nu­tri­tion, stunt­ing or wast­ing, which have a com­bi­na­tion of causes of di­etary deficit, di­ar­rhoea, worm in­fes­ta­tion, in­fec­tion, poor san­i­ta­tion, un­safe drinking wa­ter.

The NNM states no in­tent to ac­knowl­edge, an­a­lyse or ad­dress the sig­nif­i­cant pro­tein-calo­rie-mi­cronu­tri­ent deficit which af­flicts at least 50% of our pop­u­la­tion of all age groups and both gen­ders, even af­ter im­ple­men­ta­tion of our ma­jor food pro­grammes, viz., ICDS for four decades, mid­day meal pro­gramme for two decades, and the public dis­tri­bu­tion sys­tem (PDS) since the early 1980s. This has been ad­e­quately brought out in the NNMB re­peat sur­veys, the last be­ing ‘Diet and Nu­tri­tional Sta­tus of ru­ral Pop­u­la­tion: Preva­lence of Hy­per­ten­sion and Di­a­betes among adults and In­fants and Young child Feed­ing Prac­tices’ (2011-12) [nn­m­bindia.org/1_n­n­m­b_third_re­peat_ru­ral_ Sur­vey___tech­ni­cl_re­port_26.pdf ].

The mis­sion does not even ac­knowl­edge this fact, let alone de­velop strate­gies to ad­dress In­dia’s great di­etary deficit.

‘Pop­u­lar­i­sa­tion of low cost Nu­tri­tious Foods’, an in­ter­ven­tion man­dated by the Na­tional Nutri­tion Pol­icy, 1993, [http://wcd.nic.in/sites/de­fault/files/ nnp_0.pdf, Sec­tion V (iii)] to bridge this di­etary gap, could have brought about sus­tained re­duc­tion of In­dia’s mal­nu­tri­tion over time. But even to­day, this re­mains an or­phan sub­ject, not be­ing the re­spon­si­bil­ity of any min­istry. It is pre­cisely be­cause no low cost nu­tri­tious foods are avail­able in the mar­ket that the poor of all age groups are un­able to bridge their calo­rie-pro­tein­mi­cronu­tri­ent deficit, par­tic­u­larly the most vul­ner­a­ble, lead­ing to mor­bid­ity, lower pro­duc­tiv­ity and in­comes, and per­pet­u­at­ing the cy­cle of poverty. mon­i­tor­ing or con­ver­gence by the NNM is good, but can it sub­sti­tute for the hard macro and mi­cronu­tri­ent re­quire­ments to bridge the di­etary deficit?

This di­etary deficit is com­pounded by an in­for­ma­tion and knowl­edge deficit in the house­hold about ba­sic di­etary prac­tices for chil­dren, ado­les­cents and moth­ers, for ex­am­ple, what is a bal­anced diet within lim­ited bud­gets, the age at which an in­fant should be given com­ple­men­tary feed­ing, proper growth of ado­les­cent girls and boys, ad­e­quate preg­nancy weight gain, im­por­tance of san­i­ta­tion. Knowl­edge deficit is high­est among the most vul­ner­a­ble, viz., agri­cul­ture/con­struc­tion labour fam­i­lies, where al­most all wasted chil­dren are found. In­dia’s mal­nu­tri­tion could re­duce much faster had the NNM worked out a strat­egy for bridg­ing both the di­etary and in­for­ma­tion deficit in house­holds through an ef­fec­tive nutri­tion ed­u­ca­tion cam­paign reach­ing the most vul­ner­a­ble house­holds. un­for­tu­nately, the NNM ig­nores them both.

Be­hav­iour change and di­etary di­ver­si­fi­ca­tion by pro­vid­ing in­for­ma­tion and aware­ness at the com­mu­nity/fam­ily level is some­thing that has re­peat­edly been rec­om­mended – right from the Bhore com­mit­tee re­port of 1946 and the first five-year plan on­wards. How­ever, this very pow­er­ful in­ter­ven­tion con­tin­ues to elude a strat­egy and pro­gramme even af­ter six decades. ev­i­dence from the Kar­nataka multi Sec­toral Nutri­tion Pilot Projects es­tab­lishes that just be­hav­iour change over a pe­riod of one year can bring about 3-4% de­crease in un­der­weight and wast­ing of chil­dren, im­prove­ment of ado­les­cent girls’ BMI, preg­nancy weight gain, and re­duc­tion

Clearly, the present in­ter­ven­tions are not work­ing, nei­ther at the an­gan­wadi, nor in the house­holds. And it is un­likely that in­ad­e­quacy in in­fants’ di­ets will be ad­dressed through dig­i­tal­i­sa­tion and tar­get set­ting. It can only be ad­dressed through ad­e­quate and timely com­ple­men­tary feed­ing.

in low birth weight. un­for­tu­nately, the NNM has not marked this as a pri­or­ity ob­jec­tive.

The in­ter-gen­er­a­tional as­pect, too, linking un­der­weight and un­der­nour­ished ado­les­cent girls with un­der­weight, mal­nour­ished moth­ers, who give birth to ei­ther low birth weight or mal­nour­ished ba­bies, is also com­pletely ig­nored. The ado­les­cent girl is the crit­i­cal link in the in­ter-gen­er­a­tional, life­cy­cle and holds the key to the nu­tri­tional health of the next gen­er­a­tion. The mid­day meal pro­gramme is the only nutri­tion pro­gramme for the school-go­ing girl child be­tween the age of 6 to 14 years, but it is a sub­sti­tute meal worth about ₹7 per day, not an ad­di­tion­al­ity to bridge the calo­rie-pro­tein-mi­cronu­tri­ent deficit. The Sa­bala pro­gramme was in­tro­duced in 200 dis­tricts in 2011, but its cov­er­age and nu­tri­tional com­po­nent is weak. most im­por­tantly, there is no mech­a­nism at the vil­lage level that en­sures that in­ter­ven­tions for the nu­tri­tional needs of the girl child, the ado­les­cent girl and the ex­pec­tant mother op­er­ate in con­ti­nu­ity and si­mul­ta­ne­ously – the only strat­egy that can break the in­ter-gen­er­a­tional cy­cle in the short­est time.

With­out hav­ing iden­ti­fied and ad­dressed the root causes of un­der­nu­tri­tion and mi­cronu­tri­ent de­fi­cien­cies of more than 50% of the pop­u­la­tion, it is no sur­prise that our global Hunger In­dex rank­ing has dropped from 97 to 100 in 2017, or that In­dia’s nu­tri­tional sit­u­a­tion is termed as ‘se­ri­ous’ both in the global Nutri­tion re­port as well as global Hunger In­dex. as long as nutri­tion gov­er­nance and stake­hold­ers con­tinue to view nutri­tion and food se­cu­rity in terms of sub­sis­tence and sur­vival, of fill­ing the stom­ach, and not in terms of good health or well­ness, the sit­u­a­tion will per­sist. Nutri­tion se­cu­rity is a sub­ject that has not even en­tered into the realm of public de­bate.

ad­dress­ing the causes of In­dia’s mal­nu­tri­tion, as de­scribed above are doable and have been done in the pilot projects in the two most back­ward blocks of De­vadurga in raichur district and chin­cholli in gul­barga district. The nu­tri­tional sta­tus of chil­dren, ado­les­cent girls and women has im­proved dra­mat­i­cally through be­hav­iour change and ad­di­tional di­etary sup­ple­men­ta­tion, strate­gic and prac­ti­cal con­ver­gence and real time mon­i­tor­ing. To know more about it, take a look at www.kar­nut­mis­sion.org.

Just be­fore an­nounc­ing the NNM, the min­istry of women and child de­vel­op­ment took a rather dis­turb­ing de­ci­sion. on Novem­ber 23, it in­formed the states that it was dis­con­tin­u­ing sev­eral ad­min­is­tra­tive costs of the ICDS from De­cem­ber 1, 2017, and re­duc­ing the cen­tral share for staff salary to 25% from the ex­ist­ing 60%. This is bound to cause se­ri­ous fi­nan­cial dis­lo­ca­tion in the states, just as the fi­nan­cial year is end­ing. Not a very en­cour­ag­ing start for the NNM – or what­ever is left of it.

It is pre­cisely be­cause no low cost nu­tri­tious foods are avail­able in the mar­ket that the poor of all age groups are un­able to bridge their calo­riepro­tein-mi­cronu­tri­ent deficit, par­tic­u­larly the most vul­ner­a­ble.

Rao, IAS (Retd), is ad­vi­sor, Kar­nataka Com­pre­hen­sive Nutri­tion Mis­sion. Views are per­sonal.

Percentage of chil­dren aged 6-23 months re­ceiv­ing ad­e­quate diet

Courtesy: kar­nataka nutri­tion mis­sion

House­hold coun­selling about san­i­ta­tion and the in­ter-gen­er­a­tional cy­cle of mal­nu­tri­tion in a vil­lage in De­vadurga block of Raichur district, Kar­nataka

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