The average Indian suffers from nutrition deficiency. Right policy interventions can help them â€“ and boost economic growth too
“Raising of nutritional standards has to be an important aspect of development in India, but improvement in these standards cannot be gauged solely with reference to any particular item or items within the food group. With extension of irrigation over large parts of the country, increasing use of fertilisers and better seeds, and the use of power for certain agricultural operations, a new pattern of intensive agriculture which provides a more complete and balanced diet may be expected to evolve.”
— First five-year plan, 1951
“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, time lines and monitorable targets will be put in place within six months.”
— Budget document, 2014
Jagdish Bhagwati, perennial Nobel prize contender, and Arvind Panagariya, now deputy chief of the NITI Aayog, in their India’s Tryst with Destiny (2012), have sought to debunk the myth of India’s malnutrition, which often invites comparisons with Sub-Saharan nations. Their broad thesis is that India is indeed improving its record with the rising incomes post liberalisation.
And yet something must be amiss, as the two quotations above show. Sixty-four years after the first five-year plan expected the nutritional standards to evolve, the finance minister was calling for a mission-mode programme to no more than halt the deteriorating situation. It is three years now since that announcement. The strategy is yet to come out of the government’s closet. What the latest budget says on this theme is: “Mahila Shakti Kendras will be set up at village level with an allocation of Rs 500 crores in 14 lakh ICDS Anganwadi Centres. This will provide one stop convergent support services for empowering rural women with opportunities for skill development, employment, digital literacy, health and nutrition.” It remains to be spelt out how and what will be done for nutrition.
The nutrition crisis continues to stare at us, despite the fact that India is the fastest growing large economy today. In running after GDP growth, the human development index has probably been given a short shrift.
People like us, from the urban middle class, are apt to think of malnutrition as something about poverty and welfare state. But, as Bhagwati and Panagariya point out, “There are serious questions over policy initiatives required currently to secure nutritional improvement. Unlike the concern with the poor alone, this issue is seen as cutting across all classes of the population.”
The India Health Report on Nutrition, prepared by Transform Nutrition Consortium and released by health minister JP Nadda in December 2015, shows more than 35 percent women in the 15-49 age group suffer from chronic energy deficiency (CED) as a result of poor intake of calories and other nutrients. Their height and weight measurement, calculated as body mass index (BMI), is below the set standard. A BMI of less than 18.5 kg/m2 is an indicator of CED.
The National Family Health Survey 4 (NHFS-4, 2015-16) data that has come out in early March shows some improvement on one count but not on the other. The percentage of women with BMI below normal has come down from 35.5 of NHFS-3 of 2005-06 to 22.9, and for men the numbers are down from 34.2 to 20.2. However, on obesity and overweight (BMI above 25), the numbers for women have gone up from 12.6 to 20.7 and for men from 9.3 to exactly double at 18.6.
Obesity too is a form of malnutrition, which refers to both undernutrition, i.e., problems of deficiencies, and overnutrition, i.e., “problems of unbalanced diets, which include consuming too many calories in relation to energy requirements, with or without low intake of micronutrient-rich foods”, according to Global Hunger Index.
The average Indian – man, woman or child – is malnourished on all counts: calorie intake, protein intake, iron and calcium levels, leave alone factors that developed countries worry about, such as vitamins and trace elements like zinc or magnesium.
Of course, in a country as diversified as ours, it is difficult to define ‘the average Indian’ on the basis of nutrition. Besides, there are marked divides, such as the rural-urban divide or those running across income groups. Then there are far too many cultural, religious and regional differences to count. Despite all that, experts are unanimous that, for all our economic growth and food production, we are a country of the malnourished. Also, cultural habits and traditions too contribute to our undernourishment (problems of deficiencies) or malnourishment (problems of unbalanced diets), yet government interventions big and small (think of PDS and ICDS) could have and still can go a long way in correcting the picture.
Addressing this problem makes sense not only for an old-fashioned welfare-centric policymaker but also for a neoliberal, market-oriented policymaker. A conclusion from the 2012 Copenhagen Consensus notes: “The economic benefits a country experiences as a result of improving nutrition are tremendous. Each dollar spent on reducing chronic undernutrition has a $30 payoff.”
Says agriculture scientist RB Singh, a Padma Bhushan awardee: “Fulfilling the nation’s nutritional requirements should be the biggest priority. If we don’t, physical and mental inferiority owing to poor intake of protein, calories and micronutrients will get assimilated in our genetic make-up. The population will not only be physically stunted but intellectually dwarfed as well. It’s called an epigenetic effect caused by malnutrition.”
C is for calories and cereals
In the Indian diet, nearly 70-80 percent requirement of the daily energy is fulfilled through cereals – mainly rice and wheat, and to a lesser extent, maize, sorghum and millets. This applies across income groups, with the higher income groups fulfilling 50-60 percent of their requirement through cereals. Fuelled by this demand (as well as fuelling it), India’s cereal production has increased five and a half times from 1951 to 2015. We grow almost 103-105 million tonnes of rice and 92-93 million tonnes of wheat – altogether 200 million tonnes of cereals, though in the last two decades, grain production has not increased.
According to the Economic Survey 2016, per capita availability of cereals has reduced from 510 gm per day in 1991 to 401 gm in 2013. “The cereal intake of the bottom 10 percent in rural India continues to be about 15-40 percent less than the cereal intake of the top decile of the population,” says NC Saxena, the food commissioner appointed by the supreme court. “For those who are around or below the poverty line, this has to be understood as a distress phenomenon, as with the marginal increase in their incomes over time, they are forced to cut down their food consumption to meet other pressing demands that were not considered important: school books, clothes, healthcare, electricity and fuel expenditure, tobacco and liquor.” Saxena, a former top bureaucrat who was also a member of the planning commission as well as the UPA-time National Advisory Council, calls the unexpected decline of per capita calorie consumption despite reduction in poverty the “calorie consumption puzzle”.
This puzzle, Singh says, “points to the importance of other factors like access to food, commodities, prices, efficacy of social protections and awareness. Dietary diversification among high-income groups is expected, but the decrease in cereal consumption is not a good sign.” He cites a consistent decline in calorie intake since the 1980s – across all income categories, even among those with very low incomes.
The appalling situation has persisted even after India implemented one of the largest food security programmes in the world – through the National Food Security Act, 2013, providing subsidised food grains. Nutrition should have been the cornerstone of food security.
KR Venugopal, who served as secretary to prime minister PV Narasimha Rao, had noted in his analysis of the food security law: “Nutrition security is the bigger whole, of which food security is a part. In simple terms, we may say that food security is about hunger and all that it implies, while nutrition security is about hidden hunger and all that it implies, and people need security from both these onslaughts.”
Under this law, BPL beneficiaries, forming nearly 67 percent of the population, get wheat (Rs 2 per kg), rice (Rs 3 per kg) and coarse grain (Rs 1 per kg) – all put together five kg per member per month. Right-to-Food campaigners call it inadequate. The five kg of grain work out to 166 grams per day, enough for about two rotis. The Indian Council for Medical Research prescribes 14 kg grain monthly per adult and seven kg for children below 12 years. Campaigners want at least 10 kg grain monthly per person.
Moreover, the irony is, a large chunk of beneficiaries under NFSA don’t get their share of food grains. The loophole lies in the public distribution system (PDS), through which government procures, stores, transports and allocates food grain to consumers. Due to leakages in the system at different levels, diversion of subsidised grains in the market, exclusion of BPL card holders and existence of ghost beneficiaries, the implementation of the food security law leaves much to be desired.
The government’s preferred solution to plug these loopholes is possible introduction of Aadhaar-based direct benefits transfer (DBT), or handing the beneficiary cash equivalent of the monthly ration. Activists, however, fear that a beneficiary may end up using cash for other apparently pressing needs. Cash transfer would also ignore the nutritional role of the PDS entitlements, in delivering not only calorie-rich food commodities but also pulses, edible oils and fortified salts, as provided in certain states. Bhagwati and Panagariya, on the other hand, argue that often beneficiaries themselves encash PDS entitlements.
- PDS should be transparent and accountable
- Increase in the monthly grain allocation per person per month
- Ensure proper implementation of NREGA, which aims to promote livelihood security and thereby improving nutrition security
- Improve the purchasing power of the population
- Revisit the export policy of food grains
Too little protein
Cereals to some extent fulfil the requirement of proteins, vitamins, calcium and iron. According to Dr Ashok Mishra, community medicine expert and retired chief medical officer, Uttar Pradesh, “Cereals contain six to 12 percent protein and fulfil at least 50 percent of daily protein requirement. But it is inadequate. Therefore, protein deficiency continues to persist.”
Since the 1940s, the country is battling with protein-energy malnutrition. An improvement, though, has been noticed in dealing with it. Still, the average Indian consumes about 100 percent less protein than people in other developing countries at par with India. The rhetoric of providing grain for everyone has resulted in a compromise on protein, which largely comes from pulses and dairy products in vegetarian diets and from meat, fish and eggs in non-vegetarian diets. In fact, the focus on grain has tangentially led to lesser production of pulses, since state and central governments don’t procure them from farmers, always an encouragement to growing a particular crop.
“Our pulse production fails to meet the requirement of the population. The Green Revolution increased wheat and rice production, but it has pushed pulses to the margins. Therefore, we are importing 2-5 million tonnes of pulses annually,” says Singh.
The proportion of protein on our plate has shrunk due to the rising prices of its cheapest source – pulses. The country needs about 25 million tonnes of pulses annually, but production is 18-19 million tonnes. Per capita availability has therefore declined from 69 grams per day in 1961 to 43 grams per day in 2013, according to the Economic Survey of 2016.
“Good quality protein is getting out of reach due to the high price of pulses,” says B Sesikaran, former director, National Institute of Nutrition, Hyderabad. “Since we largely consume cereals, only a small amount of protein, and that too of poor quality, is absorbed by the body.”
It is reflected in the poor stunting and undernourishment figures. Increased protein consumption is therefore a policy concern of which pulses is the priority.
Policy experts comment high prices will continue on a regular pattern if the mismatch in demand and supply will continue to exist. India’s imports account for a significant share of the rest of the world’s production, about 30 percent in the case of tur.
Arvind Subramanian, the chief economic advisor, ministry of finance, in his report in September last year noted that if demand continues to race ahead of domestic supply, it will become increasingly difficult – and expensive – to make up the shortfall from abroad. Instead, he called for incentivising pulses production through minimum support price (MSP) and related policies.
Subramanian made a point that food security in pulses must be achieved by boosting domestic productivity and supply. Due to weak procurement by the government, farmers sell their product at prices below the MSP. For the pulse growing farmers, who are small and marginal, policymakers suggest raising the MSP of Rs 40/kg for gram and MSP of Rs 60/kg for both urad and tur.
He also recommended building up stock of two million tonnes of pulses with targets for individual pulses, especially tur (3.5 lakh tonnes) and urad (2 lakh tonnes).
This can bring pulses within the ambit of PDS, as states like Chhattisgarh, Tamil Nadu, Andhra Pradesh, Himachal Pradesh and Kerala have already done. The challenge is its implementation and the extra cost burden on the PDS. The benefit, however, will be seen in the nutritional status of the country.
Meanwhile, it makes sense to look at forgotten foods too. Cereals like millets, jowar, bajra, ragi and kodo, having a higher protein content (nine to 14 percent) also disappeared from the plates. “Millets, called a miracle crop, because they are a rich source of protein and nutrients like vitamins and iron, have disappeared from our diets after the Green Revolution,” says Dr Ved Prakash Singh, scientist, Krishi Vigyan Kendra, Deendayal Research Institute, Satna, Madhya Pradesh.
Some states have experimented with providing millets cheap. “But implementation has been uneven,” says Suman (single name), vice-president of the Food First Information and Action Network. “Karnataka is way ahead of other states, while Odisha has prepared a draft plan. Other states continue to mull over its significance and overall impact on its citizens. It is pertinent to ensure procurement and adequate implementation of millets under the NFSA.”
Proteins have a body-building function: growth, maintenance of the tissues. They are vital to development and all our enzymes, hormones, antibodies and many other factors are generated from the proteins we take in. The normal wear-and-tear of the body is also repaired using protein. Animal sources – meat, fish, eggs and milk – provide first-class proteins, which contain all required amino acids (the building blocks of proteins). Plant sources – with the notable exception of soya – are deficient in some amino acids. Soya, like animal protein, provides all the amino acids the human body requires.
Here lies a problem: since a majority of Indians get their proteins from dals, they usually do not get all the amino acids required.
“Soyabean is the richest among the pulses, having the highest protein content, some 40 percent. It is yet to be popularised in India. Ironically, we are exporting soya instead of adding it to our plates,” says Sesikaran.
Milk, another good source of protein, is out of reach for a large proportion of the population. Adults should have at least 150 ml of milk daily, while children and pregnant or lactating mothers should consume 250 ml daily, but a majority hardly get even a third of it, what with its constantly increasing prices.
Bhagwati and Panagariya suggest import of powdered milk could have helped. “The demand should be shifted towards dairy products for good nutrition. It is possible only if there is a policy to ensure increased availability. It depends on domestic production and imports. In the last three years, the key component of food inflation has been milk. Clearly, easing the imports through reduced tariff on milk powder could have greatly alleviated the shortage of this critical item. But the government did not take the advantage of this channel.”
Experts say eggs and fish, which provide high-quality protein without the accompanying fattening and arterial hardening that meat from poultry and livestock tend to cause, could address India’s protein hunger in a huge way. Basanta Kar, a nutrition expert with the Food and Nutrition Coalition, says, “Addressing protein hunger is possible only if the country starts investing in the farming and livestock sector. Leafy vegetables, cereals and rice, consumed largely, do not fulfil the protein requirement of the body.” There are, of course, factors that prevent widespread popularisation of eggs and fish.
Introduction of eggs in two major nutritional schemes, Integrated Child Development Scheme (ICDS) and Mid-Day Meal (MDM) scheme, remains a contentious issue due to cultural and political reasons. These schemes were introduced to fill the gap between the recommendatory dietary intake (RDI) and the actual intake. However, with the introduction of cash transfer in ICDS and Aadhaar in MDM, these two initiatives, so critical for nutrition, are going to face all the more challenges.
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- Introduce pulses in PDS
- Increase the MSP on pulses
- Introduce technology mission to increase pluses output
- Introduce soyabean in ICDS and MDM instead of exporting it
- Introduce millets in PDS as mentioned in NFSA
- Restructure ICDS to monitor nutrition intake
- Improve nutritive quality of food in MDM
- Micronutrient dearth
As is the case with protein, essential micronutrients like vitamin A, vitamin B12, vitamin C, iron, iodine and zinc are also missing from Indian diets. As per the NFHS-4, 53.1 percent women in the 15-49 age group, and 58.4 percent children aged six-59 months are anaemic. Mishra adds, “The percentage of anaemic women is much more than the figures projected in the data.”
“Absorption of iron is dependent on protein intake. To retain iron in the body, sufficient quantity of protein is required, which Indians are not getting,” says Kar. The body needs a daily input of 20-30 mg of iron, but only 1-3 mg is absorbed through the diet taken by an average Indian. Out of this one mg is lost per day in an adult and 12.5 mg per 28-day cycle in a menstruating woman.
Iron is a vital element for as a component of haemoglobin, it plays an important role in ferrying oxygen across the body. It’s especially important for children and pregnant women. Iron deficiency is particularly common in women who do not get adequate iron in their diet to supplement what is lost during menstruation.
Its absorption is a complicated process. “The presence of carbonates, phosphates and dietary fibres in cereals inhibits the iron absorption. Only two to five percent iron is taken up by the body if it is a cereal-based diet, whereas it is as high as 10-20 percent in case of meat and fish consumption,” says Mishra. For vegetarians, some 50 gm of green leafy vegetables, bajra and ragi in grains can meet the daily requirement of iron.
India’s anaemia problem cannot be combated through diet alone, according to experts: they say pills, fortification of food grain, salt, etc. have an important role to play in addressing the deficiency in children, adolescent girls, pregnant and lactating mothers. Even this has its limitations. “Iron and folic acid supplements provided under anaemia prophylaxis programmes have failed to reduce the anaemia burden. Almost 70 percent women reported not receiving the tablets, while many discontinued due to symptoms like constipation,” says Kar.
According to NNMB, nearly 50-81 percent households cannot meet the 50 percent requirement of riboflavin and vitamin A. A similar percentage of school-going children could not meet 50 percent of the required daily allowance of calcium, vitamin A, riboflavin and vitamin C.
Vitamin A, one of the essential micro nutrients in the growing years, is required to form retinal pigment needed for vision. Children from six months to six years are most vulnerable to night blindness and dry eyes due to deficient vitamin A intake.
Similarly, riboflavin deficiency is the most widespread deficiency among children and women. Required for protein and energy metabolism, poor intake of riboflavin causes soreness of the tongue, redness and burning sensation in the eyes. Inadequate food intake makes zinc deficiency common in children. Low birth weight infants have the milder form of this deficiency.
The predominant dependence upon cereal-based diets fails to cure these micronutrient deficiencies. Experts say inclusion of green leafy vegetables and milk in the diet can curb the problem to an extent. “A cereal-based diet limits intake of micronutrients. Intake of leafy vegetables can show slight improvement in the nutrient statistics as they are rich sources of vitamins, riboflavin, iron and folic acid and calcium,” says Kar. At least 400 gm of fruits and vegetables should be consumed, as per the RDI. At least 100 grams of vegetables can be provided through food supplementation under ICDS. There have been piecemeal attempts to achieve it. There is scope to introduce local vegetables in ICDS and MDM through MNREGA. “Instead of digging ponds if we start growing local vegetables and provide the same for MDM and ICDS, we will see a change,” suggests Kar. Also, there has to be an investment in improving the transportation and storage of vegetables.
Another way could be to promote traditional but forgotten foods through food festivals like Sattvik organised at the Indian Institute of Management, Ahmedabad. The annual event, launched in the early 2000s, seeks to popularise traditional plants and vegetables via delicious dishes. It not only encourages healthier food habits through lesser known nutrient-rich food items, but also helps farmers to increase their income.
- High priority to control anaemia
- Maximum coverage of iron and folic acid supplementation programme
- Increased coverage of vitamin A supplementation programme
- District-level health survey to monitor prevalence of micro-nutrient deficiencies
- Restart the National Nutrition Monitoring Bureau
- Linking agriculture with nutritional requirements of the country; promoting production and consumption of fruits and vegetables
- Research on micronutrients interaction within the body
- Large scale campaign on priority basis to promote nutrition education
- Promotion of food festivals popularising use of traditional plants and vegetables rich in nutrition
The nation has witnessed a rainbow of revolutions – a White Revolution for milk, Yellow and Golden for fruits and vegetables, and Blue for fish and aquaculture. And yet, it continues to face hunger and malnutrition.
Singh calls it an enigma. “Despite a rainbow of revolutions, we have high incidence of poverty and undernutrition. The country has witnessed unprecedented gains in food production, registering record production of more than 250 million tonnes of food grains, almost 250 million tonnes of fruits and vegetables, and at least 130 million tonnes of milk in the last one year. Even their consumption has grown the rate 12-15 percent per year,” he says.
But a runaway inflation in food items, a recurrent phenomenon over the past decade, has restricted access to a balanced diet, leading to nutritional disparity. “The production of nutritious foods which are today in the diet of a large number of households can be divided into two categories – ones such as milk, egg, fish, meat, fruits and vegetables, where production has rapidly increased in last three decades but demand has increased even faster resulting in high prices and making these items out of ordinary people’s reach. On the other hand, per capita production of pulses, millets and coarse grain has been declining because farmers do not find these crops profitable, and government too has not prioritised their production,” says Saxena.
“A green signal for greater production of nutrient-rich food should be given,” says Dipa Sinha, economist and nutrition advisor to the supreme court. “Demand for such crops has to be generated. By formulating a comprehensive policy in the agriculture sector, the government will be able to intervene both at the demand and supply sides. It will not only create livelihood opportunities but also address the nutritional requirements through social security schemes like PDS, ICDS and MDM.”
Agricultural scientist MS Swaminathan, a pioneer of the Green Revolution with his high-yield varieties of grain, has said that hidden hunger can be reduced by promoting cultivation and consumption of bio-fortified crops, rich in critical micronutrients. According to him, through genetic recombinant technologies, India has produced iron-rich pearl millet and rice rich in vitamin A. These should be cultivated and distributed as a matter of policy, he suggests, and speaks of “genetic gardens of bio-fortified crops”.
To address the nutritional gap, many experts believe there is a case for fortification, that is, addition of nutrients to staples such as grain or milk, precluding the need for a varied and balanced diet. Says Sesikaran, “No country has sailed through the malnutrition problem by diet diversification alone. Even the most advanced countries address micronutrient deficiency partially through fortification.”
Abhijit Betigeri, project manager in charge of rice fortification with Path, a US-based global health NGO, says, “It’s very difficult to change people’s dietary habits. Almost 65 percent of the population consume rice on a daily basis. It’s a major source of calories. However, its micronutrient level is low. During milling and polishing, 75 to 90 percent of vitamin B1, vitamin B6, vitamin E and niacin are lost. Through fortification, we add these nutrients as well as iron, zinc, folic acid, vitamin B12 and vitamin A to the rice, increasing the content of essential micronutrients.”
The process involves powdering rice and adding to it a premix of micronutrients. This is then processed into rice-like grains, which are then added to normal rice grains in ratios ranging from 1:50 to 1:200. The fortified grain looks and tastes no different from normal grain, and people hardly notice it. Costa Rica, Nicaragua, Panama, Papua New Guinea and the Philippines have mandated fortification of rice; Brazil, the US, South Africa, Colombia and the Dominican Republic allow packagers the choice of doing so. Path has collaborated with the Karnataka government and the NGO Akshaya Patra to provide fortified rice meals to 4.5 lakh children in over 2,500 schools in the state.
“In India, fortified food grain can address the problem of hidden hunger if it is provided through social welfare schemes of government like the PDS, MDM and ICDS,” says Betigeri.
But there are difficulties: quality and cost, mainly. Last October, the Food Safety and Standards Authority of India (FSSAI) released regulations for fortification. But policymakers are yet to decide on how to keep costs under check. Says Sesikaran, “We have already started fortification of salt, milk, oil, rice and wheat. It is, however, difficult to introduce fortified food in PDS, for there is no provision of providing packaged food. Also, we provide wheat instead of wheat flour. Andhra Pradesh tried its hand in supplying fortified wheat flour through PDS in two districts. But it was discontinued.”
India has three major policy initiatives on nutrition: the National Nutrition Policy (1993), the National Nutrition Action Plan (1995), and the National Food Security Act (2013). In 2010, during prime minister Manmohan Singh’s tenure, a PM’s national council on India’s nutritional challenge was formed, and a centre-sponsored multi-sectoral nutritional programme to address maternal and child undernutrition was initiated in 200 districts deemed to be worst off.
The council on nutrition met a couple of times, but did not hold a single meeting for three years, says Biraj Patnaik, principal adviser, office of the commissioners of the supreme court. After the NDA came to power, the council faces an uncertain status. Dr Arun Gupta of Breast Feeding Association, a member of the council, says, “We approached the PMO last year for an update on the council. The reply was ‘it is not yet reconstituted’. There is no information on its dissolution either.”
Trouble is that the problem of malnutrition is indeed complex. It cannot be tackled at just one level. Several indirect interventions are required. Patnaik says, “NFSA provides for accessibility and availability but not absorbability. By absorption we mean what you consume stays in the body. But in India we are struggling predominantly with childhood diarrhoea and the reasons are poor availability of potable water and access to sanitation. Another big social determinant is education and early age of marriage. Therefore, we have a high percentage of low-birth weight babies.”
Lack of convergence among different ministries dealing with these sectors, he adds, makes nutritional security a challenge. “The nutritional crisis will continue to persist if we don’t have regular nutritional surveillance. If we don’t want to address how the crisis is developing and why it is developing then what are the chances we will be able to solve it?” he asks.
(The article appears in the March 16-31, 2017 issue of Governance Now)