Dietary deprivation: Diets sans diversity

Ensuring a diverse diet for all and not fortification of staples with chemicals should be the public policy objective to ensure that children do not go malnourished.

Children at a tribal hamlet in Attappady, Kerala.

One of the starkest findings of the recently released data of the Comprehensive National Nutrition Survey (2016-18) (CNNS) is that only 6 per cent of the children in the 6-23 months age group received what is defined as a “minimum acceptable diet” in accordance with World Health Organisation (WHO) norms. However, this information is not entirely new. The National Family Health Survey-4 (2015) had alerted us to this issue not too long ago, having found that only about 9.6 per cent of the children in the 6-23 months age group were fed the minimum acceptable diet. (The minimum acceptable diet indicator measures both the minimum meal frequency and the minimum dietary diversity, that is, food from four or more food groups.)

While the data for young children are particularly disheartening, dietary diversity is of major concern for all age groups. For instance, among two- to four-year-old children, only about 32 per cent consumed any legumes and nuts in the previous 24 hours; 16 per cent consumed eggs; 19 per cent any flesh food. Sixty-two per cent had consumed dairy products and 56 per cent vitamin-A-rich fruits and vegetables. Among five- to nine-year-old children, about 35 per cent had an egg at least once a week, and fewer than 40 per cent had fruits at least once a week. The data for 10- to 19-year-old adolescents tell a similar story. Food frequency questionnaires typically do not deal with quantity. Thus these data are likely to be concealing even higher levels of dietary deprivation.

Broken down, what this essentially means, in simple terms, is that despite the supposed attention paid to food and hunger, very few receive food that has the minimum quality considered decent for human life and health. This seems to be reinforced also by the fact that India ranks 102 in the Global Hunger Index in 2019, out of a total of 117, and is the lowest-ranking country in the South Asian region.

Impact of Socio-Economic Factors

Further, as with all data arising from the country, the variations within States, classes and sections of society remain high, and this variance points to several factors that might be associated and need to be tackled if we are to change the situation in the near future.

For instance, while about 20 per cent of the children in the 10-19 age group in the poorest wealth quintile consumed eggs at least once a week, 46.5 per cent of those in the richest quintile did so. While 20.7 per cent of the children in this age group in the poorest wealth quintile consumed fruits once a week, 66.8 per cent in the richest quintile did so. Similar differences are also seen on the basis of social groups, with Adivasis and Dalits having the least access to foods such as milk and milk products and fruits. Wide inter-State differences also exist. For example, the percentage of children aged six months to 23 months receiving a minimum acceptable diet is 35.9 per cent in Sikkim and 32.6 per cent in Kerala compared with 2.2 per cent in Maharashtra and 1.3 per cent in Andhra Pradesh.

These socio-economic differences in access to adequate and diversified diets are also reflected in differentiated nutritional outcomes. The percentage of children classified as being stunted (height for age < -2 SD) is 41.5 per cent for Scheduled Tribes, whereas it is 26.8 per cent for “others”. Similarly, while almost half (49.2 per cent) of the children in the poorest wealth quintile are stunted, 19.4 per cent are so in the richest quintile. This highlights also the importance of social determinants of malnutrition such as income, social status, location, and so on. It is in this context that some of the public demands for the introduction of eggs, millets, fruits and vegetables in school and anganwadi midday meals need to be seen. As is well known, these institutions are largely accessed by those belonging to the poorer and marginalised sections in societies who, as seen above, are also the ones who have the least access to adequate diets and are the most susceptible to malnutrition.

Interestingly, the CNNS also gives data for malnutrition disaggregated by whether the mother is vegetarian, vegetarian with eggs in diet, or non-vegetarian. Although, to draw any conclusions, this needs to be looked at while taking into account other factors such as income and caste, the data in the report show that the prevalence of malnutrition is higher among children of vegetarian mothers: 36.9 per cent of the children of vegetarian mothers are stunted compared with 30.3 per cent of children of mothers who are vegetarians but eat eggs and 32.4 per cent of children whose mothers are non-vegetarian. The corresponding figures for underweight (low weight for age) children are 35.5 per cent, 29.9 per cent and 31.1 per cent.

Micronutrient deficiencies

A major consequence of the lack of dietary diversity is micronutrient deficiency, which manifests itself, for instance, in the widespread prevalence of anaemia: 28.4 per cent of adolescents (10-19 years), 23.5 per cent of children in the 5-9 age group and 40.5 per cent of children in the 1-4 age group have been classified by the CNNS data as having anaemia, going by haemoglobin levels. The prevalence of vitamin A deficiency was found to be 18 per cent among preschool children, 22 per cent among school-age children, and 16 per cent among adolescents. The prevalence of vitamin B12 deficiency was 14 per cent among preschool children, 17 per cent among school-age children, and 31 per cent among adolescents. Such high prevalence of micronutrient deficiencies is not surprising considering the poor diets, as seen above.

The recent response of public policy to anaemia, in particular, and micronutrient deficiencies in general has been to have common staples fortified with chemicals rather than address the basic issue of dietary diversity. If anything, public programmes have denied the requirement of animal-based proteins in diets which, to a large extent, can provide an excellent source for iron and other micronutrients. Essentially, this is akin to accepting as given that a large proportion of our population should not hope to acquire its dietary requirements from “decent” food and will continue to eat essentially a cereal-based diet fortified with various chemicals to achieve some sort of micronutrient sufficiency. This is a sad, niggardly and unnecessary surrender, if human rights and equality are to remain any kind of societal goal.

Advantages Of diverse diets

While the technical juries continue to be out on whether fortification really has any impact on anaemia, and whether high-dose vitamin A should continue to be given considering the levels of current prevalence, one thing is certain—a diverse diet achieves a positive health impact over and above a balanced and safe fulfilment of micronutrient deficiencies. To give a few examples, a wholesome diet rich in animal-based foods (including dairy products and meats) is an obvious source of protein, the macronutrient that is essential to the growth and maintenance of the human body, along with micronutrients. Fruits and vegetables are rich sources of micronutrients but also of another important component of decent diets, dietary fibre. This fibre content is considered necessary for proper bowel function and also helps to lower cholesterol, maintain a normal healthy weight and lower the risk of diabetes, heart disease and cancers such as colon cancer.

Nature, in its wisdom, never provides foods that contain single nutrients in isolation. Since nature has provided complex foods that offer many different advantages simultaneously and even more so in combination with other foods, singular chemical additions can hardly hope to compensate or replace decent quality diets in the thalis of our people. That, surely, is the reason that the diets of the richest are seen to be the highest in a wide variety of these foods. In comparison, the not-so-well-off, tribal people, for instance, survive largely on rice even when culturally and historically they need no introduction to diverse diets, and in fact could teach others a thing or two on that front.

India has some of the largest food-related programmes in the world. About two-thirds of the population is covered under the public distribution system (PDS), more than eight crore children receive supplementary nutrition from the Integrated Child Development Services (ICDS), and about 11 crore children receive midday meals in schools. These provide an enormous potential to attain decent diets for a large part of the population, especially the most vulnerable. However, these programmes are hamstrung by a centralised and mechanical system that allows no community participation or flexibility of dietary choice and low budgets that hardly allow dietary diversity. Even something as simple as introducing eggs in school meals gets mired in controversy or is denied simply because of a reluctance to allocate sufficient resources.

An alternative vision could be one in which the rights of forest-dwelling communities over forest produce are protected; commons are protected and encouraged; farmers are actively supported to grow millets, fruits and vegetables through long-pending agricultural reforms; everyone is assured decent minimum wages; small farmer cooperatives are organised; local markets overflowing with a variety of local produce in every locality (as so visible in much of the north-east) are nurtured, vendors are actively and respectfully acknowledged as an essential part of a community and encouraged and trained to provide low-cost but safe and healthy foods; public food programmes are made culturally appropriate, decentralised and adequately diverse; processed foods are curtailed and discouraged; ultra-processed (junk) foods are highly taxed; and non-vegetarian foods are respected as valuable components of a diet rather than disparaged as somehow impure.

Considering that it is largely women who create meals, apart from working to produce food as farmers and livestock rearers, the implications on women’s labour of many of these recommendations must not be underestimated. However, reducing the drudgery of women at household and community levels would be a truer test of our technological abilities than the processing of foods. Public services that allow community feeding, such as childcare services and community kitchens, would greatly assist families in the achievement of decent “multicoloured” diets on all our plates.

All this would require higher investments, but more than that an alternative vision that looks to support all peoples to feed themselves well and enough. So many years into our democracy, with our claims of economic progress, can we not proudly guarantee fresh and diverse foods rich in vegetables, fruits and, if desired, a variety of animal-based food to all our children and people?

Vandana P rasad is a community paediatrician and public health professional with over 25 years of work in the social sector, especially in the field of public health and nutrition for vulnerable communities. Dipa Sinha teaches at the School of Liberal Studies, Ambedkar University Delhi. Both authors are associated with the Right to Food Campaign.