Malnutrition – Social Justice Notes

In India, malnutrition is responsible for 68% of all deaths among children under the age of five and contributes to 17% of the total disability-adjusted life years. Additionally, approximately 30% of the world’s stunted children and nearly 50% of severely wasted children under the age of five are found in India. Moreover, almost half of the world’s “wasted or acutely malnourished” children (those with a low weight-for-height ratio) reside in India.

Facts about Malnutrition in India

• Malnutrition is a significant problem in India, according to various reports.
  • A large percentage of India’s population suffers from undernourishment, as per the Food and Agricultural Organisation (FAO).
  • India ranks poorly on the Global Hunger Index, indicating a severe hunger problem in the country.
  • Malnutrition is the primary cause of death for children under the age of five in India, as per a report by the Indian Council of Medical Research (ICMR).
• A high percentage of children under five in India are stunted.
  • UNICEF reports indicate that 38% of children under five in India are stunted.
  • Children from disadvantaged backgrounds, such as Scheduled Caste, Scheduled Tribe, and Other Backward Classes, are particularly vulnerable, with approximately 40% being stunted.
• India has a high number of underweight and stunted children, according to UNICEF reports.
  • India ranks 10th on the list of countries with the highest number of underweight children.
  • India ranks 17th on the list of countries with the most stunted children.
• Rajasthan, Madhya Pradesh, and Uttar Pradesh are the states with the highest percentage of underweight births in India.

Prevalence and Types of Malnutrition in India

Malnutrition is a significant public health issue in India. According to the World Health Organization (WHO), malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy or nutrients. Malnutrition can manifest in several ways, such as undernutrition, overnutrition, and micronutrient deficiencies. In India, malnutrition is particularly prevalent among children, women, and marginalized communities.

Here are some facts and data on the prevalence and types of malnutrition in India

1. Undernutrition:

Undernutrition is one of the most common forms of malnutrition in India. It refers to a lack of adequate nutrition, including insufficient intake of calories, protein, and essential micronutrients. According to the National Family Health Survey-5 (NFHS-5), 2019-20, 22.7% of children under five in India suffer from wasting (low weight for height), and 34.7% of children under five suffer from stunting (low height for age). The prevalence of wasting is particularly high in some states, such as Bihar (27.9%), Jharkhand (27.6%), and Madhya Pradesh (27.1%). Similarly, the prevalence of stunting is high in several states, including Uttar Pradesh (42.2%), Bihar (40.3%), and Jharkhand (38.8%).

2. Overnutrition:

Overnutrition is also becoming increasingly common in India, particularly among urban populations. It refers to an excessive intake of calories, which can lead to obesity and related health problems. According to NFHS-5, the prevalence of overweight and obesity among women (age 15-49 years) in India is 20.7% and 5.5%, respectively. The prevalence of overweight and obesity among men (age 15-49 years) in India is 18.6% and 2.9%, respectively.

3. Micronutrient deficiencies:

Micronutrient deficiencies, such as vitamin A, iron, and iodine deficiencies, are also prevalent in India. According to the Global Nutrition Report 2020, India has a high prevalence of anemia, affecting 40.1% of women (age 15-49 years), 19.8% of men (age 15-49 years), and 53.2% of children under five. Iron deficiency is the leading cause of anemia in India. Similarly, vitamin A deficiency is prevalent in some states, such as Bihar, Uttar Pradesh, and Madhya Pradesh.

4. Malnutrition among marginalized communities:

Marginalized communities, such as Scheduled Castes, Scheduled Tribes, and Other Backward Classes, are particularly vulnerable to malnutrition in India. According to NFHS-5, the prevalence of wasting among children under five is highest among Scheduled Tribes (30.5%) and Scheduled Castes (25.4%). Similarly, the prevalence of stunting is highest among Scheduled Castes (42.6%) and Scheduled Tribes (41.2%).

Causes of Malnutrition in India

• Poverty and inequality
  • Around 27% of the Indian population lives below the poverty line.
  • Poor families lack access to nutritious food and safe drinking water.
  • Marginalized communities, such as Scheduled Castes and Scheduled Tribes, are particularly vulnerable to malnutrition.
• Poor infant and young child feeding practices
  • Poor feeding practices are common, such as delayed initiation of breastfeeding, inadequate exclusive breastfeeding, and inappropriate complementary feeding.
  • Only 44.6% of children under six months of age are exclusively breastfed in India.
• Lack of nutritious food
  • Many families cannot afford to purchase nutrient-rich food, such as fruits, vegetables, dairy products, and protein sources.
  • The quality of food available in the market may be poor, with high levels of contamination, adulteration, and nutrient loss during storage and transportation.
• Poor health and sanitation
  • Inadequate sanitation facilities and poor hygiene practices can lead to diarrheal diseases, which can cause nutrient loss and increase the risk of malnutrition.
  • Only 44.8% of households in India have access to improved sanitation facilities.
• Climate change and natural disasters
  • Climate change and natural disasters can exacerbate malnutrition in India, such as droughts and floods that cause crop failure, leading to food shortages and malnutrition.
  • India is the seventh most affected country by climate change in the period from 2000 to 2019.
  • Discrimination against women and girls can lead to unequal distribution of food within households, with women and girls receiving less food than men and boys.
  • Girls are often married at a young age and become pregnant before their bodies are fully developed, which increases their risk of malnutrition.
• Gender inequality
• Poor access to healthcare
  • Lack of access to healthcare, including prenatal and postnatal care, can lead to poor maternal and child health outcomes, including malnutrition.
  • Rural areas often have inadequate healthcare infrastructure, with few doctors and healthcare facilities.
• Low literacy rates and education levels
  • Low literacy rates and education levels are associated with poor health outcomes, including malnutrition.
  • Educated mothers are more likely to have good knowledge and practice of infant and young child feeding practices.
• Food insecurity
  • Food insecurity, which is the lack of consistent access to enough food for an active, healthy life, is a major cause of malnutrition in India.
  • Around 14.5% of India’s population is undernourished, and food insecurity is higher in rural areas.
• Limited government spending on health and nutrition
  • The Indian government spends only around 1% of its GDP on health and nutrition, which is lower than many other countries.
  • This limited spending can hinder the implementation of effective nutrition programs and interventions.

Impact of Malnutrition on Indian Society

Malnutrition is a significant issue in India and has a considerable impact on society. Here are some facts and figures on the impact of malnutrition in India:

Health Impact

• Malnutrition can lead to various health problems, such as stunted growth, wasting, being underweight, anemia, and micronutrient deficiencies.
• According to the National Family Health Survey-4, around 38% of children under five years of age in India are stunted, and 21% are wasted.
• Malnutrition also affects maternal health, with 58% of Indian women being anemic.
• The impact of malnutrition can be lifelong, with malnourished children having a higher risk of chronic diseases in adulthood.

Economic Impact

• Malnutrition has a considerable economic impact on India, leading to increased healthcare costs, decreased productivity, and reduced economic growth.
• A World Bank report estimated that India loses around 2-3% of its GDP due to malnutrition each year.
• Malnourished children are more likely to have low educational attainment and decreased cognitive abilities, leading to reduced productivity and earning potential in adulthood.

Social Impact

• Malnutrition has a significant social impact in India, with malnourished individuals facing discrimination, stigma, and reduced social mobility.
• Malnourished children are more likely to experience developmental delays and impaired cognitive abilities, leading to difficulties in school and reduced social opportunities.
• Malnourished individuals are also at higher risk of poor mental health outcomes, such as depression and anxiety.

Environmental Impact

• Malnutrition has environmental implications, with food insecurity and poor agricultural practices leading to land degradation and loss of biodiversity.
• The impact of climate change, such as droughts and floods, can exacerbate malnutrition by reducing crop yields and food availability.

Increased Healthcare Costs

• Malnutrition leads to increased healthcare costs, with malnourished individuals requiring more medical interventions and longer hospital stays.
• The economic burden of malnutrition falls primarily on families and the healthcare system, leading to increased poverty and decreased healthcare resources.

Higher Mortality Rates

• Malnutrition is a significant contributor to mortality rates in India, with malnourished children having a higher risk of death from preventable diseases such as diarrhea and pneumonia.
• As per the National Family Health Survey-4, malnutrition accounts for 68% of total under-five deaths in India.

Reduced Human Capital

• Malnutrition leads to reduced human capital, with malnourished individuals having lower educational attainment and reduced cognitive abilities.
• This results in decreased productivity and earning potential in adulthood, perpetuating the cycle of poverty and malnutrition.

Gender Disparities

• Malnutrition affects girls and women disproportionately, with women and girls often receiving less nutritious food and having restricted access to healthcare and education.
• The impact of malnutrition on maternal health and child development perpetuates gender disparities and hinders progress toward gender equality.

Social Exclusion

• Malnutrition is associated with social exclusion, with malnourished individuals facing stigma and discrimination.
• This exclusion can lead to reduced social mobility and perpetuates the cycle of poverty and malnutrition.

National Security

• Malnutrition has implications for national security, with malnourished individuals being less physically fit and having reduced cognitive abilities.
• A malnourished population can lead to decreased economic growth, social unrest, and political instability, which can impact national security.

Government Policies and Programs for Malnutrition in India

Food security is a major concern in India, and two key programs have been developed to address this issue: the Public Distribution System (PDS) and employment generation schemes. However, addressing malnutrition directly or indirectly is equally important, as the ultimate test of food security lies in the nutritional well-being of all.

I. Programs to Address Malnutrition

A. Women and Child Development Sector

1. Integrated Child Development Service Programme (ICDS)

• A unique program that provides integrated services to vulnerable groups, including children up to 6 years of age and expectant/nursing mothers.
• Objectives of the ICDS include improving the nutritional and health status of children, laying the foundation for proper psychological, physical, and social development, reducing mortality and morbidity rates, regulating effective coordination of policy and program implementation, and enhancing the capability of mothers to take care of their children’s nutritional needs.
• The ICDS program covers either a tribal or rural block or a cluster of urban slums in an urban project, with preference given to those areas with comparatively larger proportions of tribal people and other disadvantaged categories.
• The program has expanded gradually and by March 1993, it consisted of 3066 projects with 19.5 million children and mothers receiving supplementary nutrition under the program.
• The entire expenditure of 2871 centrally sponsored ICDS projects (of the total 3066 projects in place by the end of March 1993) is borne by the Central Government, barring expenditure on supplementary nutrition which concerned State Governments incur. Expenditure on the rest of the projects is borne by the state governments.
• Positive impacts of the ICDS program include lower infant mortality rates, better immunization coverage, and better coverage of prophylaxis programs of Vit. A and iron, improved nutritional status of children, and a lower percentage of low birth weight babies. However, inadequate community participation and too much dependence on the government have been identified as negative impacts.

B. Midday Meal Scheme

1. A program aimed at improving the nutritional status of children in primary and upper primary classes.
2. The scheme provides a free cooked meal to school children in government schools and government-aided schools, including special training centers for children with disabilities.
3. The program is managed by the Ministry of Education and is implemented in all states and Union Territories.
4. Positive impacts of the scheme include increased school attendance, improved health and nutrition status of children, and increased enrollment rates.

C. National Rural Health Mission (NRHM)

1. A flagship program of the Ministry of Health and Family Welfare aimed at providing accessible, affordable and quality health care to rural populations, especially the poor and vulnerable groups.
2. The program has a strong focus on maternal and child health, including immunization, nutritional supplementation, and health education.
3. Positive impacts of the NRHM program include improved maternal and child health, reduced infant and maternal mortality rates, and improved access to health services in rural areas.

Scheme	Details
Integrated Child Development Scheme	– Launched in 1975 – Target group: women and children below 6 years of age – Implemented by the Ministry of Women and Child Development – Provides nutrition, medical health check-up, immunization
National Nutrition Policy	– Launched in 1993 – Implemented by the Ministry of Women and Child Development – Objective: achieve optimum nutrition for all
Mid-Day Meal Scheme	– Launched in 1995- Target group: children aged between 6 years to 14 years
National Health Mission	– Launched in 2013- Absorbed 2 other missions: National Rural Health Mission and National Urban Health Mission – Implemented by the Ministry of Health and Family Welfare
Indira Gandhi Matritva Sahyog Yojana	– Implemented by the Ministry of Women and Child Development – Focuses on providing cash incentives to pregnant and lactating mothers
National Nutrition Mission	– Also called POSHAN Abhiyaan – Objective: make India free of malnutrition by 2022 – Target groups: pregnant and lactating mothers, children, and adolescents – Aim to reduce undernutrition by 2%, low birth weight by 2%, and anemia by 3% – Objective is to reduce the proportion of stunted children in the population to 25% by 2022

Global Efforts to Combat Malnutrition in India

1. United Nations International Children’s Emergency Fund (UNICEF)

UNICEF has been at the forefront of tackling malnutrition in India. UNICEF has been supporting the Indian government in developing and implementing programs and policies that focus on maternal and child nutrition. They have initiated programs such as Community Management of Acute Malnutrition (CMAM), which aims to detect and treat severe acute malnutrition among children aged 6-59 months. UNICEF also collaborates with local organizations to improve health and hygiene practices in rural and urban areas, thereby reducing malnutrition rates.

2. World Food Programme (WFP)

The World Food Programme has been active in India since 1963. WFP has been working with the Indian government to implement school feeding programs that provide nutritious meals to school-going children. WFP has also launched a program to provide food assistance to vulnerable populations such as pregnant women, lactating mothers, and children under five years of age in areas affected by natural disasters and conflict. The WFP has also launched initiatives to improve the availability and access to nutritious food in remote and underprivileged areas in India.

3. Bill and Melinda Gates Foundation

The Bill and Melinda Gates Foundation have invested millions of dollars in India to combat malnutrition. The foundation has supported several initiatives in India, such as the POSHAN Abhiyaan (National Nutrition Mission), which aims to improve nutritional outcomes for children, adolescent girls, pregnant women, and lactating mothers. The foundation has also partnered with Indian organizations to develop nutritious and affordable food products and supplements.

4. The World Health Organization (WHO)

The World Health Organization has been working closely with the Indian government to implement policies and programs that address malnutrition. WHO has been involved in initiatives such as the Integrated Child Development Services (ICDS), which provides a package of services, including supplementary nutrition, immunization, health check-ups, and referral services. WHO has also provided technical support to improve the quality of nutrition interventions in India.

5. The Global Alliance for Improved Nutrition (GAIN)

The Global Alliance for Improved Nutrition is an international organization that works to improve the nutritional status of people globally. GAIN has been working in India since 2011 and has partnered with the Indian government to implement programs to address malnutrition. GAIN has launched initiatives such as the Large Scale Food Fortification Program, which aims to fortify staple foods with essential vitamins and minerals to improve their nutritional content. GAIN has also supported the development of nutritious and affordable food products for vulnerable populations in India.

Challenges in Addressing Malnutrition in India

1. Poverty and Food Insecurity: Poverty is a significant contributor to malnutrition in India. According to the World Bank, around 364 million people in India live below the poverty line. Poor households cannot afford to buy nutritious foods, leading to inadequate calorie and nutrient intake. Food insecurity, especially in rural areas, is another challenge. In many parts of India, agriculture is the primary source of income, and crop failures or low yields can lead to food shortages.
2. Inadequate Health Care Services: Inadequate healthcare services also contribute to malnutrition in India. Many rural areas lack basic healthcare facilities, leading to poor health outcomes. Access to clean water and sanitation is also limited in many areas, which can lead to diarrhea and other waterborne diseases that contribute to malnutrition.
3. Lack of Awareness: Lack of awareness about proper nutrition and feeding practices is another significant challenge. Parents who are not educated are less likely to know about proper nutrition, leading to poor child nutrition. Cultural beliefs and practices also contribute to malnutrition in India. For example, in some parts of India, cow’s milk is given to infants instead of breast milk or formula, which lacks essential nutrients and can lead to malnutrition in infants.
4. Limited Coverage: The government’s interventions, such as the Integrated Child Development Services (ICDS), National Health Mission (NHM), and Mid-day Meal Scheme, do not cover all children and pregnant and lactating women in India. This is due to inadequate funding and limited resources. As a result, many children and women do not receive the necessary nutrition and healthcare services.
5. Poor Implementation: Poor implementation of interventions is another significant challenge in addressing malnutrition in India. Some interventions are not implemented effectively due to inadequate resources, poor planning, and corruption. For example, in some areas, the food provided under the Mid-day Meal Scheme is of poor quality, leading to food wastage and inadequate nutrition.
6. Gender Inequality: Gender inequality is another significant challenge in addressing malnutrition in India. Women and girls are often marginalized and have limited access to education and healthcare, which can lead to poor health outcomes. This can also lead to poor nutrition outcomes for women and girls, as they may not receive the necessary nutrients during pregnancy and lactation.
7. Climate Change: Climate change is also contributing to malnutrition in India. Extreme weather events, such as floods and droughts, can lead to crop failures and food shortages. This can result in inadequate nutrient intake and malnutrition, especially in vulnerable populations.
8. Poor Infant and Young Child Feeding Practices: Poor infant and young child feeding practices are prevalent in India. For example, exclusive breastfeeding rates are low, and complementary feeding practices are inadequate. This can lead to poor growth and development and contribute to malnutrition in children.
9. Lack of Nutritious Food Options: The lack of nutritious food options is also a challenge in addressing malnutrition in India. Many people in India rely on staple foods such as rice and wheat, which are not nutrient-dense. The availability of fruits, vegetables, and animal-source foods is limited in many parts of India, leading to inadequate nutrient intake.
10. Inadequate Food Fortification: Food fortification, the process of adding essential vitamins and minerals to staple foods, can improve nutrient intake and reduce malnutrition. However, food fortification is not widely implemented in India, and where it is implemented, it is often inadequate. This is due to inadequate regulations, limited resources, and inadequate monitoring and evaluation systems.

Way Forward to Tackle Malnutrition in India

1. Improving access to nutritious food

• According to the National Family Health Survey-4 (NFHS-4), 2015-16, 38.4% of children under the age of five in India are stunted due to malnutrition.
• A study conducted by the Indian Council of Medical Research (ICMR) in 2019 found that the average per capita consumption of pulses and vegetables is much lower than the recommended levels for a balanced diet.
• The National Food Security Act, 2013 aims to provide subsidized food grains to approximately two-thirds of the population, or 800 million people.

2. Education and Awareness

• A study conducted by the World Food Programme in 2019 found that only 44% of children in India under the age of six are given a diverse diet that includes fruits and vegetables.
• The mid-day meal scheme, which provides free meals to children in government schools, has been successful in improving school attendance and reducing malnutrition among children.

3. Addressing underlying causes

• According to the World Bank, 24% of the population in India lives below the poverty line.
• Women in India often have lower social status and less access to education and employment opportunities, which can lead to poorer health outcomes for them and their children.

4. Community participation and empowerment

• The POSHAN Abhiyaan, launched in 2018, aims to improve the nutritional status of children under the age of six and pregnant and lactating women by promoting community-based approaches to address malnutrition.
• The Integrated Child Development Services (ICDS) scheme, which was launched in 1975, aims to provide a package of services to improve the health and nutrition of children under the age of six and pregnant and lactating women.

5. Monitoring and evaluation

• The NFHS-4 found that the prevalence of stunting among children under the age of five decreased from 48% in 2005-06 to 38.4% in 2015-16.
• The government has developed the National Nutrition Monitoring Bureau (NNMB) to collect data on the nutritional status of the population and monitor progress toward reducing malnutrition.

6. Fortification of food

• Fortification of staple foods such as wheat, rice, and salt with essential micronutrients can help improve the nutritional status of the population.
• The Food Safety and Standards Authority of India (FSSAI) has launched a nationwide campaign to promote the fortification of rice and wheat flour with iron, folic acid, and other micronutrients.

7. Addressing water and sanitation

• Poor water and sanitation can lead to diarrhea, which can exacerbate malnutrition.
• The Swachh Bharat Abhiyaan, launched in 2014, aims to improve sanitation and hygiene practices across India.

8. Improving healthcare

• Access to healthcare services, particularly for women and children, is crucial in addressing malnutrition.
• The government has launched various schemes such as the Ayushman Bharat Yojana and the Pradhan Mantri Matru Vandana Yojana to improve healthcare access for vulnerable populations.

9. Addressing food waste and losses

• India is one of the largest producers of food in the world, yet a significant amount of food is lost or wasted each year.
• Reducing food waste and losses can help improve access to nutritious food for the population.

10. Addressing climate change

• Climate change can have a significant impact on food production and availability, particularly for vulnerable populations.
• Addressing climate change and its impacts on food security is crucial in addressing malnutrition in the long run.

Addressing malnutrition in India requires a comprehensive and multi-faceted approach, including improving access to nutritious food, promoting education and awareness, addressing underlying causes, empowering communities, monitoring progress, fortifying food, improving water and sanitation, improving healthcare, addressing food waste and losses, and addressing climate change. By implementing these strategies and sustained efforts, India can work towards reducing malnutrition and ensuring that every citizen has access to a healthy and balanced diet.

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