A national consultation of health experts has called for a stop to the history of bad science and misconceived advice that has long dominated India's nutrition policies. They stress the need to "put nutrition back into our food" and understand what it would mean to initiate comprehensive policies that enable the healthy survival of India's children.
The government's effort to combat India's malnutrition crisis has long focused on providing cereals, in the belief that the body only needs calories - energy rich foods - to grow and survive. This erroneous thinking is severely damaging the health of India's poor, who are slipping deeper into a malnutrition crisis, warns Veena Shatrugna, former Deputy Director, National Institute of Nutrition, Hyderabad.
Dr. Shatrugna was on a panel of health experts speaking at a national consultation on India's malnutrition crisis, organised by the Mumbai-based Narottam Sekhsari Foundation, a private funding agency that works in the field of health and education. The foundation has recently released its comprehensive document on issues linked to malnutrition in India, which is based on two national consultative workshops with a panel of health experts, a review of existing literature, and research into the missing policy linkages.
Historically, India presents an example of what can go wrong when 'experts' cross their academic disciplines and draw interpretations from narrowly focused scientific studies, Dr. Shatrugna says. In the absence of a broad reading and understanding of the wider issue, these experts fail to read the small print on scientific studies and make erroneous recommendations. The consequence of this approach, seen over the past 60 years in India, is the serious compromise of metabolic function and rising indices of malnutrition. Children's bodies are shrinking in height and weight, due to the severe food deficiency they suffer from.
According to Dr. Shatrugna, about 33 per cent of men and 36 per cent of women have a Body Mass Index (BMI) below 18.5 in India, while seven per cent have BMI below 16.0. BMI is a measure of weight for height, and any figure below 18.5 is considered to be unhealthy. BMI values below 16 are unheard of even in Sub-Saharan Africa, she says.
Meanwhile, according to the World Health Organisation, almost 50 per cent of Indian children, who suffer severe deficits in weight and height, are in this condition because of food deprivation. In Maharashtra, a relatively developed State, questions raised in the December 2011 Assembly session led to the revelations that 65 infants are dying each day, with 13,683 infant deaths occurring between January to September 2011, raising questions about the abysmal nutrition status of mothers. (According to official figures around 7.4 lakh births were recorded during this corresponding period). Despite this the State government remains in denial of its looming malnutrition crisis.
The anomalies in deciding the right nutrition go back to the years of the British Raj. In 1937 British experts analyzed and gave nutritive value to over 300 foods, classifying them under calories, proteins, carbohydrates, fats, etc. (Government publication, Health Bulletin No. 23(5), 1937, 1st edition). It was recognized by then that some foods like cereals (rice, wheat), potatoes, sugar, are concentrated sources of calories, but most other foods contain multiple nutrients such as proteins, vitamins and minerals, along with calories.
The anomalies in deciding the right nutrition go back to the days of the British Raj. (Pic: A tribal village in Bastar, a part of the central Indian tribal crescent: Children under five years are paying the heaviest price, with high mortality and morbidity due to malnutrition.)
This basic rule was unfortunately forgotten by the colonial masters, as also by subsequent governments in Independent India. From the late 1940s onwards, government food programmes have focused on cereals, which are high in calories, and - perhaps more importantly - a cheap source of energy for the poor. "There was no pause to consider the non-cereal portion of the diet, which provides most of the essential nutrients in requisite amounts", Dr. Shatrugna says.
During the late 60s, when famine raged in some parts of the country, many 'giants' in nutrition claimed that if people eat enough calories, they get to consume sufficient protein - tissue, muscle and bone building nutrients - as well. But there is a fatal flaw in this thinking. Such 'macro' food sources do not provide the 'micro' nutrients - vitamins and minerals - which contain enzymes needed for physiological function of the body. In planning diets, the first requirement is proteins, fats, minerals and vitamins. The need for carbohydrate-rich foods that fulfil energy requirements follows thereafter.
"The planners and scientists, with their own Nehruvian tryst with destiny, were in a hurry and ignored the small print in the studies. Indians lost the war even before it started. It was our own government - which looked up to science more than the people it governed - that took away the right to food, scientifically", Dr. Shatrugna says.
The dietary recommendations of the planners, meanwhile emphasised vegetarian food and homogeneity for the whole nation, overlooking the varied cultural and regional differences across the country, where many eat meat. The plans also overlooked the question of how many Indians can bring balance to their daily diet when they cannot afford to buy dal and the two or three vegetables needed to accompany their rice or roti.
Foisting a diet based on a laboratory understanding of nutrition, the government's public food support programmes and its agriculture policies have thus condemned the poor to eat a monotonous daily diet of cereals that are of limited nutrition value.
Hailing from the upper caste and class, these planners overlooked the fact that their own children ate a balanced diet rich in a variety of fresh vegetables, fruits, milk and its products, nuts, sprouts, seeds, apart from cereals. They did not conceive a reality where the poor only ate a cereal with chillies and tamarind water. A diet consisting of bajra roti and chutney has calories and fibre. But if foods rich in proteins and vitamins are not included in the diet, the calories merely get converted into fat.
A cereal-based diet takes no account of the special needs of growing children, pregnant and lactating women. Children for instance, have small stomachs and seek to eat a variety of food in small quantities through the day. A sesame seed ladoo of around 250 grams could be a highly nutritive meal in itself for a child. But India's Integrated Child Development Scheme (ICDS) only offers one meal of khichdi (rice and dal) every day, without variation.
Even during the 1960s top nutritionists failed to reflect on how poor children could sustain themselves on a diet of mere cereals. Even if a child ate cereals for the whole day it would not get adequate calories from such a diet.
"By then it was well known that children needed fat in their diet, and many middle class mothers added a small dollop of ghee to their children's daily diet. These children were also offered variety through fruit, egg and milk. The children of the poor, however, had to make do with low-cost, scientific choices and not crave any of these foods, as a sacrifice to the nation", Dr. Shatrugna says.
As a result of this over-emphasis on calories India's poor now face a massive inadequacy of minerals and vitamins, leading to the diagnosis of "micro-nutrient deficiencies". This has given rise to the lobbies that argue endlessly over macro or micro nutrients. Taking advantage of this scenario is the multi-million dollar micro-nutrient industry that vociferously lobbies to sell its pre-packaged, ready-to-eat foods, vitamin tablets, fortified or genetically modified foods, amongst others chemical-laden products, to the government food programme for malnourished children.
In Narsapur Mandal, Medak district of Andhra Pradesh the community was sensitised to the domestic and economic value of nutrition gardening - growing dark green leafy vegetables, yellow-orange fruits and vegetables and vitamin C-rich fruits. At the end of six years, up to 90 per cent of households saw its health value for their children, and were growing these foods. Women farmers here are responding to diversification from water-intensive paddy and sugarcane cultivation to nutritionally relevant horticulture after receiving training and support, the study reports.
Instead of focusing on improving household diets with a basket of nutritious foods like green leafy vegetables, seasonal fruits, sprouts, nuts and seeds, not just wheat and rice, the government programmes are increasingly looking at quick technology fix solutions to under-nutrition. But experts say synthetically produced, single nutrient fortification of food, vitamin tablets, or ready-to-eat packaged foods cannot combat overall macro and micro nutrient deficiencies and can even cause harm.
For instance, unsupervised mass pumping of vitamin-A tablets along with polio immunisation, especially amongst malnourished or sick children, is known to cause fatalities. In a mass campaign where the object is to achieve targets and "capture" children, such supervision is scarce and fatalities will occur, leading to an erosion of faith in government sponsored programmes.
The tendency towards quick fix solutions is evident in government's encouragement to industry to fortify cereals with synthetically produced iron and zinc. In Gujarat, for instance, wheat flour is being fortified with iron, despite the fact that wheat is rich in phytates which inhibit iron absorption. (Phytates are phosphorus compounds found primarily in cereal grains, legumes and nuts. They bind with minerals such as iron, calcium and zinc and interfere with iron absorption). Furthermore, the marketing of fortified wheat flour is pushing small enterprises such as chhakis (small flour mills) out of business.
"Micro-nutrient fortification of our food is going to create a nutrition mess and the body will face a new range of burdens and problems. It will foreclose any attempts to improve the diets of children, both qualitative and quantitative", Dr. Shatrugna says. While such measures may be warranted in short-term crisis situations, it is not normal and the bulk of our efforts must be geared towards the long-term goal of putting enough of real food on the plates of our poor, she says.
NGOs at the workshop criticised the Maharashtra government programme of purchasing corporate produced, ready-to-eat packaged foods for children in the ICDS programme. This programme has been challenged in a writ petition filed with the Mumbai High Court. While the State wastes large amounts of money in procuring such foodstuff of questionable value, tribal families have no taste for it. Neither has anyone shown them how to add value to it. There are other localised, cheaper and more nutritive methods of ensuring that poor households get access to food, they say.
No chemical, industrial additive, genetically modified, fortified or therapeutic food should be introduced in the health and public food programmes, the experts held. Every effort must go towards obtaining food that is fresh, wholesome and locally available. This should be encouraged through the growth of kitchen gardens and agriculture policies that provide water, promote horticulture and vegetable cultivation for local consumption.
Studies meanwhile show that green vegetables and fruits contain 40-50 bio-active chemicals vital to prevention of diseases like cancer and in arresting degenerative processes. It is not just satisfaction of hunger that we have to talk of, but nutrition education and nutrition security through food that is locally grown, fresh and wholesome. Such natural foods provide a more effective and cheaper source of folic acid, vitamin C, iron or calcium. The promotion of local kitchen gardens and large-scale food-based programmes that boost production and consumption of fruits and vegetables, needs financial and infrastructure support.
India's rich biodiversity provides a gold mine at our doorstep. Today one-third of its fruits and vegetables perish for lack of facilities to store and conserve them. Development of agro industries could provide enormous income generation capacity for village women. The National Family Health Surveys shows high levels of anaemia in states like Punjab or Haryana where the focus of agriculture is rice and wheat. The difference is evident in Himachal Pradesh, where anaemia rates are lower because of the plentiful fruits and vegetables grown there, and are a part of the local diet.
The emphasis on small scale agro-industries in villages could focus on the production of 'dehydrated leaf powder' (from alpha/beta-carotene rich
sources such as spinach and drumstick leaves). Pilot studies indicate its feasibility and demonstrate their good nutritive value and acceptance in the
community. These products, from natural, indigenous sources, produced by local labour, could be used to "fortify" food offered to millions of children
through the ongoing national supplementary feeding programme, nutritionists suggest.