The findings of one of the largest nutrition surveys ever conducted in the country on the shifting conditions of undernutrition, over-nutrition and obesity expose the disconnect between the one-sided and much-eulogised India growth story and the abysmal state of nutrition and health of children and adolescents. It is not surprising that the Bharatiya Janata Party (BJP)-led government, which makes a virtue of almost every programme conducted under its regime in comparison with previous regimes, has chosen to gloss over the findings of the largest-ever survey commissioned by it. The findings clearly are not an election issue for the government; ironically, neither has it been for the opposition.
The Comprehensive National Nutrition Survey (CNNS), commissioned by the National Democratic Alliance (NDA) government after the National Statistical Commission approved the survey’s design in 2016, was conducted from 2016 to 2018. Led by the Ministry of Health and Family Welfare and done in collaboration with the United Nations Children Fund (UNICEF), the CNNS has findings that corroborate the results of the National Family Health Surveys (NFHS 3 and 4) with respect to data on nutrition status and morbidity among children. It is apparent from the results that little has substantively changed in terms of nutritional status for the children of the poor even as a burgeoning category of lifestyle-related diseases has emerged. However, the government’s focus continues to be on “eating right” and behavioural patterns, oblivious to the fact that both are a function of basic access to food and social entitlements.
In terms of sample size, the CNNS is far bigger than the NFHS and includes preschool children, schoolgoing children and adolescents covering geographically, socially and economically diverse population cohorts.
Chronic malnutrition
At the very outset, the CNNS indicates that chronic malnutrition or stunting of children under five years of age declined by only one-third between 1992 and 2016. This is the length of time from the country’s turn to neoliberal reforms under the Congress government and their aggressive pursual by the NDA governments that followed. Stunting, the CNNS findings say, remains alarmingly high at 38.4 per cent. More than half of the women in the reproductive age were found anaemic, with the survey showing a strong correlation between household wealth and the prevalence of anaemia. For instance, more than 60 per cent of all anaemia cases had to do with poor nutrition and iron deficiency.
The findings highlight the shifting patterns of diet and lifestyle resulting in obesity, hypertension and other non-communicable diseases (NCD), yet the overarching finding of the survey is the interlinkages of large-scale nutritional deficiencies in terms of the reduced consumption of the basic basket of food items. The survey also points out the persistent gender disparities in the nutritional status of girl children and poor nutritional indicators among the Scheduled Castes (S.Cs) and the Scheduled Tribes (S.Ts), trends that reflect in the NFHS reports as well. The objective of the survey was to collect nationally representative data on the nutritional status of preschoolers (0-4 years), school-age children (5-9 years) and adolescents (10-19 years) through a comprehensive set of interviews, anthropometric data and body composition.
The survey claims to have a nationally representative data for children in the age group of 5 to 14 years in particular, but it states that there were either limited data or nothing at all on micronutrient deficiencies and on NCDs for this age cohort. Yet the data on the whole do not seem to indicate a hugely alarming picture even though the survey cautions that NCDs need to be taken seriously.
Two things stand out in the survey: the first is the link between the nutritional status of children and the nutritional and educational status of the mother; the second is the link between the nutritional status of children with household wealth. The survey underscores the systemic determinants of malnutrition, the most dominant of which is poverty and socioeconomic inequalities. “Food, disease and care” (in that order) “have a critical impact on nutrition”, states the report.
Almost all of stunting took place within the first 1,000 days after conception. Nearly 31 per cent of the mothers of children in the 0-4 age group, 42 per cent of the mothers of children in the 5-9 age group, and 53 per cent of the mothers of adolescents had never attended school. Less than half of the mothers surveyed had been exposed to any mass media in five of the nine States designated as Empowered Action Group States—Assam, Bihar, Jharkhand, Rajasthan and Uttar Pradesh.
In the southern States, such exposure to the mass media was as high as 80 per cent. It was also the case in Haryana, Maharashtra, Mizoram, Punjab and Sikkim. The survey makes the point that addressing malnutrition before women got pregnant was crucial to the nutritional status of the child, it being the “only effective exit to malnutrition within the lifecycle.”
Public health experts have raised concerns about adopting quick-fix approaches to address nutrition prior to conception. Ready-to-use therapeutic foods were prescribed for severe and acutely malnourished children too, the efficacy of which has been debunked in recent studies. One lobby that stands to gain commercially from this is the food fortification industry, which offers quick-fix solutions at a price—either paid for by the government or by the individual—to address micronutrient deficiencies.
Income and education
As important as the survey’s findings that repeatedly bring out the correlation between the educational status of women and the nutritional status of children is the age of marriage of women. According to the report, ensuring that girl children stayed at school longer would automatically delay the onset of pregnancy. Ideally, ensuring that girls “stayed” longer in education, and not merely produced healthy children, was a responsibility that the state ought to guarantee rather than placing the onus on individuals. The survey reveals a worrying statistic relating to education of women: 53 per cent of the mothers surveyed had no education at all. Only 20 per cent of mothers of preschool children, 12 per cent of mothers of schoolgoing children and 7 per cent of mothers of adolescents had completed 12 years of schooling.
Wide differences prevailed among States in levels of educational attainment of mothers. In Kerala and Tamil Nadu, 60 per cent and 51 per cent respectively of mothers of children in the 0-4 age group had completed 12 years of schooling whereas fewer than 20 per cent of mothers of preschoolers in at least 16 States had completed less than 12 years of schooling.
Insufficient diet
The dietary patterns reveal a sad state of affairs. More than half of the children and adolescents consumed a vegetarian diet (without eggs). Only 36-40 per cent adolescents reported consuming a non-vegetarian diet while the remaining were vegetarian or egg-eaters. Significantly, fewer than half of the mothers and caregivers interviewed reported having a vegetarian diet.
As many as 57 per cent of children in the 0-24 month age group were breastfed within one hour of birth, with women among S.Ts reporting a high prevalence of early initiation of breastfeeding—this was much more than the national average. Rural and S.T. women breastfed their children up to one year.
The number of children who received complementary food from six months onwards indicates rural-urban disparities and income differentiation. Complementary feeding was proportionate to wealth; in other words, the more the household wealth, the more the chance of a baby being fed complementary food. Thus more urban children got complementary food than rural children. In terms of breastfeeding too, the lower the wealth, the longer the chances of a baby being breastfed and weaned much later.
Forty-two per cent of women in the lowest wealth quintile reported giving complementary food (58 per cent did not give) compared with 68 per cent of women in the highest wealth quintile. On an average, only 53 per cent of infants received supplementary feeding, which appeared to be clearly a function of poverty and wealth and not any “behavioural” factor. Both insufficient dietary diversity and infrequent meals increased the risks of morbidity and mortality. Even without spelling it out, the survey clearly makes a case for food intake and food diversity. Only 42 per cent of the children in the 6-23 month age group were fed the required minimum number of times a day and only 21 per cent in the same age cohort were fed an adequately diverse diet containing four or more food groups. Dietary diversity was lower for children whose mothers were vegetarians. Again, a larger number of urban children received a diverse diet than rural children.
Other factors affecting such diversity were household wealth and the level of the mother’s education. Among the higher wealth groups, dietary diversity went up even as the meal frequency came down. Only 6 per cent of the children were fed a minimum acceptable diet. The percentage went up for children in wealthier households and where women had higher levels of education. In 10 out of 30 States, fewer than 5 per cent of the children had a minimum accepted diet.
Among the States where the minimum dietary consumption was considered good were Sikkim at number one, followed by Kerala (where the Prime Minister claimed in an election rally in 2016 that the infant mortality rates among tribal people were as high as in Somalia), Arunachal Pradesh, Odisha, Tripura, Himachal Pradesh, Uttarakhand, and Jammu and Kashmir. In 14 States the levels of minimum dietary consumption were below the national average of 6.4 per cent. These included the otherwise “high performing” States of Gujarat, Maharashtra, Andhra Pradesh, Uttar Pradesh, Madhya Pradesh, Rajasthan, Tamil Nadu and Karnataka.
Dietary diversity
Dietary diversity was the lowest in Jharkhand and Rajasthan and the highest in Meghalaya. The percentage of children receiving a minimum meal frequency ranged from 22 per cent in Andhra Pradesh to a maximum of 67 per cent in Sikkim.
Only a meagre 9 per cent of children in the 6-23 month age group received iron-rich foods. While the mother’s diet influenced such consumption among children in general, there were variations in religious groups owing to dietary patterns. Consumption of iron-rich food was significantly higher among Christian and Muslim children, probably indicating a high degree of non-vegetarianism among them. The lowest consumption of iron-rich food was in Haryana and the highest in Meghalaya.
Alarmingly, in seven out of 30 States, fewer than 5 per cent of the children in the 6-23 month age group consumed iron-rich foods. A mere 5 per cent of preschool children in the 2-4 years age group consumed fruits and vegetables rich in vitamin A while 96 per cent consumed grains, roots and tubers; 62 per cent consumed dairy products such as milk and curd.
The child’s consumption patterns were determined by the level of schooling the mother had received and household wealth. The consumption of flesh foods (meat and fish) and eggs was highest among Christian children.
A distinct rural-urban divide was visible here as well. More urban children than rural children consumed dairy products, indicating a function of affordability rather than taste. Even if local geographical factors were considered for the differential levels of consumption of dairy foods, the wide differential patterns in the consumption of fruits and vegetables was inexplicable. For instance, the consumption of fruits and vegetables was the highest in Kerala and the lowest in Rajasthan.
Jammu & Kashmir, Kerala far better
The consumption patterns among adolescents showed worrying trends, showing how the deprivation that began in early childhood continued in the adolescent stages as well. Ninety per cent of them told the surveyors that they consumed dark green leafy vegetables at least once a week and not daily. Two-thirds of schoolgoing children consumed milk or curd once a week, and eggs, fish or chicken less frequently. Only 40 per cent ate fruits; 35 per cent ate eggs and 36 per cent ate either fish, meat or chicken.
Gender biases too were evident in the patterns of consumption. Among adolescents, a higher proportion of males consumed milk, curd or eggs than females. All this was again related to the mother’s education levels and household wealth. Fruit, for instance, was not consumed as frequently. It ranged from 18 per cent in Bihar to as high as 79 per cent in Goa. While 4 per cent in Haryana reported consuming eggs, 85 per cent in Tamil Nadu reported doing so. Some 86 per cent in Kerala reported consuming fish or chicken compared with 3 per cent in Himachal Pradesh.
There is increasing evidence to suggest that where midday meals in schools (India has the largest school feeding programme in the world) have been more inclusive in terms of dietary variations, with little hang-ups about serving eggs and where strong state support exists, the nutritional outcomes appear to be better for both the mother and the child. Kerala is not a high per capita income State, yet the nutritional indicators for children, adolescents and women are far superior to other States. The nutritional indicators in Jammu and Kashmir, too, are far better than many States, including Gujarat and Maharashtra.
Stunting, wasting
The survey shows that 35 per cent of children under five are stunted, 17 per cent wasted, 33 per cent underweight and 11 per cent acutely malnourished. But the inter-State variations tell a different story. Nearly 37-42 per cent of children in Bihar, Uttar Pradesh and Madhya Pradesh were stunted and the prevalence was much higher than the national average of 35 per cent. The prevalence of stunting was the lowest in Goa and Jammu and Kashmir, ranging from 16 to 21 per cent. Yet again, more rural than urban children were found stunted.
Household wealth was a critical indicator as 49 per cent of children in the poorest wealth quintile were found more likely to be stunted than those in the richest quintile. Among the States reporting the least levels of stunting were Jammu and Kashmir at number one, followed by Goa, Tamil Nadu, Kerala, Sikkim, Punjab, Himachal Pradesh, Delhi, Manipur, Odisha, Telangana, Uttarakhand, Andhra Pradesh, Tripura, Assam, Karnataka, Maharashtra, Haryana, Chhattisgarh, Jharkhand, Rajasthan, Uttar Pradesh, Gujarat, Madhya Pradesh, Meghalaya and Bihar. The highest prevalence of underweight children was observed in Bihar, Chhattisgarh, Madhya Pradesh and Jharkhand.
The all-India average of underweight children was 33.4 per cent. In seven States, including Gujarat, the prevalence of underweight children was higher than the national average.
The figures of stunting, wasting and underweight as brought out by the CNNS was similar to that of the NFHS 3 and 4 surveys. A higher percentage of stunting and underweight prevailed among out-of-school children (38 per cent) than schoolgoing children (20 per cent). And 45 per cent of schoolchildren were underweight compared with 34 per cent who were in school.
The prevalence of underweight was also linked to household wealth. Prevalence of underweight was the lowest in Arunachal Pradesh, Jammu and Kashmir, Manipur and Sikkim and the highest in Jharkhand. Only 4 per cent of children in the 0-9 year age group were overweight and 1 per cent obese. There was some correlation between economic status and overweight prevalence.
Under-nutrition related to adult obesity
The survey brings out interesting details on obesity as well, pointing out that under-nutrition in utero and early childhood can predispose individuals to becoming overweight and develop NCDs such as diabetes and heart disease in adulthood. Therefore, obesity was not always an outcome of overeating and sedentary lifestyles though they could be contributory factors.
Interestingly, underweight in mothers was associated with overweight and obesity in their offspring. It was also observed in the survey that rapid weight gain following acute malnutrition early in life could predispose children to excess weight and associated risks.
According to the World Health Organisation, as quoted in the survey report, “poverty was clearly associated with undernutrition, overweight, obesity, micro-nutrient deficiencies given the reduced access of poorer households and individuals to more nutrient-rich foods”. Nearly 41 per cent of preschoolers, 24 per cent of schoolgoing children and 28 per cent of adolescents were anaemic. Among adolescents, women showed higher prevalence (40 per cent) of anaemia than men (18 per cent). Iron deficiency is one of the causes of anaemia, and interestingly, rural children showed less iron deficiency than urban children.
The correlation of increased wealth with lower anaemia was observed for all age groups. But it was most prevalent among the S.Cs and S.Ts. More than half of the preschool children and one-third of the school-age children and adolescents among tribal people were anaemic. Madhya Pradesh, Haryana and Delhi accounted for high levels of anaemia among preschoolers, while the lowest levels were in Nagaland and Manipur. The CNNS showed that barring Kerala, anaemia was a public health problem in all States for the 5-9 year age group of schoolchildren. Anaemia was found to be higher among vegetarians than non-vegetarians.
Need to go beyond slogans
One of the singular elements emerging from the survey is that the basic food intake was just not enough for children and adolescents. Slogans such as “eat right” or “fit India” make sense only if there was enough of everything to go around. The CNNS also makes some standard and routine observations pertaining to behavioural hygiene and “care-seeking” behaviour, although emphasis on this has been made in passing. Isolated references in the report to “maintaining clean and hygienic environment along with active care seeking behaviour for common childhood diseases helps to ensure rapid healthy growth in early childhood”, seek to convey the notion that the onus is on the individual rather than the state (considered responsible for public provisioning of services) for behavioural change.
The survey only confirms what has been known for long—that nutritional outcomes are a function of household wealth and incomes. The bulk of Indian children are being deprived of basic food items such as fruits, vegetables, dairy items, and sources of protein in flesh foods in their daily diet, mainly because of affordability and in part, restrictions to certain foods, even eggs, mainly promoted by conservative sections and food lobbies.
India’s ranking in the recently released Global Hunger Index (GHI) is not flattering in the least. Predictably, the government is talking neither about the CNNS findings nor about the GHI.
Interestingly, the CNNS was generously funded by an Indian industrialist, raising concerns of a different kind. A complete overhaul in approach, beginning with the universalisation of the Public Distribution System, making items such as fruits, eggs and vegetables affordable for all on a regular basis and ensuring that people have the purchasing power to sustain themselves and their families, is the need of the hour.
