Over one-fifth or around 22% of children belonging to India’s richest households are short for their age – or stunted as per the World Health Organisation – according to the State of the World’s Children report released by UNICEF on October 15. Children from poorer households are worse off: Over half or around 51% are stunted. Overall, 38% of the children below four years of age are stunted.
Stunting is caused by malnutrition and both rich and poor children in India are eating badly for different reasons, said experts. “Awareness about healthy diets is low in India, even among the economically well-off segment,” said Shweta Khandelwal, additional professor and head of nutrition research at the Public Health Foundation of India.
India also has the world’s third-worst – after Djibouti and South Sudan – wasting rate: 21% of its children are underweight for their height, according to the State of the World’s Children report.
Low weight and height in early childhood are a consequence of undernutrition, and their effects may be irreversible: Children who eat insufficient food lacking in the required nutrients fall sick more often and earn less as adults, effectively keeping them trapped in poverty.
India was ranked 102 on the Global Hunger Index 2019, below Pakistan (94), Bangladesh (88) and Nepal (73). The index is a weighted average of stunting and wasting rate, and the Global Hunger Index estimates that the percentage of wasted children in India increased from 16.5% to 20.8% between 2008-’12 and 2014-’18.
The first 1,000 days
Poor nutrition in early life leads to stunting and loss of IQ, which has consequences for the economy, said Mumbai-based paediatrician Rupal Dalal, adjunct professor at the Centre for Technology Alternatives for Rural Areas at Indian Institute of Technology, Bombay, and director of health at the Shrimati Malati Dahanukar Trust.
Stunting and impaired brain development are common among those who received inadequate food in the first 1,000 days of their life, said Khandelwal. “The adverse effects are difficult to reverse,” she added.
Early childhood malnutrition increases the risk of developing non-communicable diseases such as hypertension, diabetes and heart disease in adult life, the experts concurred. In addition, stunted mothers face complications during pregnancy and this affects their children as well.
Children who were stunted in the first two years of their life go on to spend less time in school and earn up to Rs 1 lakh or less over their life than their peers of average height, said the State of the World’s Children report.
Lack of protein
The role of income is most apparent in the consumption of protein-rich foods such as milk products and eggs, according to the Comprehensive National Nutrition Survey. While 82.7% of children from the richest households aged 2 years to 4 years consume dairy products, half that number (41.3%) from poorest households do. Similarly, 8.2% of children from the poorest households ate eggs compared to 20% from the richest households.
Overall, few children aged 2 years to 4 years consumed protein-rich foods, said the Comprehensive National Nutrition Survey: 62% consumed dairy products, 15.6% ate eggs and 31.6% ate pulses and nuts, indicating few children get the required amount of proteins regardless of household income.
Children under the age of two, breastfed or not, also do not get required nourishment irrespective of household income. Only 6.4% of children in this age group had enough intake of essential nutrients, found the Comprehensive National Nutrition Survey.
Consumption of proteins was low among children from the poorer states in the eastern and central parts of India, the study found.
“Poor diets like one having inadequate quantity and quality of carbohydrates and proteins are adversely associated with child’s growth and development and may result in stunting and/or wasting,” said Khandelwal. “Failure to provide key nutrients during the first 1,000 days, a critical period of brain development, may result in lifelong irreversible deficits in brain function.”
Growing children require nutrient-dense foods, especially proteins from eggs, milk, beans, nuts and seeds, fish and meat, and good fats, Dalal said. “Lack of protein, good fats and micronutrient-dense foods which are replaced by empty calories will cause growth failure, frequent infections, lack of concentration in school, tiredness and so on,” she said.
Fruits and vegetable rare
Around 55% of children aged 6 months to 23 months who were surveyed consumed no fruit or vegetable, according to the State of the World’s Children report. But almost all children, across age groups, consumed cereals and tubers such as potatoes, according to the Comprehensive National Nutrition Survey.
Traditionally, Indian diets were rich in nutrient-rich foods such as millets and pulses. However, in a bid to ensure food security, the Indian government enacted policies that led to farmers favouring rice and wheat over fruits, vegetables and livestock products, according to Transforming Food Systems for a Rising India, a 2019 book by Cornell University researcher Prabhu Pingali.
The result is that fruits and vegetables are too expensive for many families: Only 25.4% of the poorest children aged 2 years to 4 years ate fruits and 54% vegetables, according to the Comprehensive National Nutrition Survey.
Children from the relatively richer households did slightly better – 56.7% of the richest children ate fruits and 61% vegetables. But the low numbers indicate that nutritious food is not consumed even by children whose parents can afford it.
“Most studies say that children may be considered to have adequately diversified dietary intake if they had food items from at least four of the seven food groups,” said Khandelwal. The seven food groups, as per the WHO’s infant and young child feeding practices guidelines, are grains, roots, and tubers, legumes and nuts, dairy products, flesh foods, eggs, vitamin A-rich fruits and vegetables and other fruits and vegetables.
“Lack of [food] diversity is a serious threat gradually pushing us towards hidden hunger,” said Khandelwal. “Several micronutrients, vitamins and minerals have vanished from our diets because we have substantially cut down variety in our daily meals. Most households, due to time and resource [money, education, access, availability] paucity, are moving away from traditional local recipes, vegetables and fruits to a quicker, more accessible market version of takeaway or home-delivered meals.”
It is important to emphasise balanced healthy diets with micro- and macronutrients as public health policy, she added.
As many as 38% of Indian children below four years of age, as we said, are stunted – including those belonging to the richest households. Obesity is less prevalent – 2% of all children of that age are overweight or obese, according to the State of the World’s Children report. Over 40% of children between 1 and 4 years of age are anaemic, as per the Comprehensive National Nutrition Survey.
In addition to being stunted, children from the richest households – who can afford iron-rich vegetables, fruits and meat – also reported being anaemic. Over one-third (34.2%) of such children and just under half (46%) of the poorest children reported some form of anaemia.
This simultaneous existence of anaemia, obesity and stunting/wasting is what nutrition experts call the triple burden of malnutrition”.
Inadequate protein and good fats in mother’s diet is also a reason for stunting, according to Dalal. A significant reason for faltering growth in the first few months of a child’s life is the lack of awareness about right breastfeeding techniques, said Dalal. Ignorance about how an infant should latch on correctly to the lower areola exists not just among mothers but also doctors, nurses and healthcare workers.
Breastfed children’s diets do not contain enough proteins and other growth micronutrients. “It is also important to include vegetables and fruits and [a] variety of whole grains like bajra, sorghum, millets and so on,” said Dalal. “They [the children] should not be exposed to junk foods like biscuits, wafers, street foods like batata-vada, bhajiya, [or nutritional supplements like] Pediasure, Horlicks, high sugar/jaggery foods, sugary drinks and cakes and pastries.”
The WHO recommends that the child be introduced to solid and semi-solid foods – called complementary foods – at six months, as breast milk is no longer sufficient to meet the needs of the growing body, the Comprehensive National Nutrition Survey report noted. However, the complementary foods fed to most children lack proteins and other micronutrients, said Dalal. “They are monotonous and watery and do not contain seeds, nuts, legumes and animal proteins,” she said.
Nutrition cannot be improved by standalone programmes and India’s attempts at tackling multiple forms of malnutrition are diluted, said Khandelwal. “Health fads, yo-yo diets, poor environmental factors, exposure to domestic violence, smoke or alcohol during the first 1,000 days also impact stunting,” said Khandelwal.
“Many issues around income, education, gender, women empowerment, poverty, social inclusion/welfare schemes, sanitation etc are related and known to have an impact on nutritional status of the masses,” she added. “All these have to be addressed under a smooth harmonised multi-sectoral strategy guided by effective leadership to have a sustained impact.”
Khandelwal emphasised the need for multidisciplinary strategies. “Right now, most programmes and policies are a bunch of single-focus top-down initiatives with no conversations between the multiple sectors who should be talking and assuming collective responsibility to advance science and translate those into public health policy/action,” she said.
A plan for improving diagnostic and tertiary care, providing trained staff and enhancing the capacity to deal with issues related to malnutrition are necessary, Khandelwal pointed out. “Let us not associate nutrition with merely how much and what to eat but all other related behaviours to have a meaningful impact on public health and nutrition,” she added.
This article first appeared on HealthCheck.in, a publication of the data-driven public-interest journalism non-profit IndiaSpend.