Dietary diversity – key to tackle malnutrition among children

The recently published NFHS- 5 data presents a grim picture of the nutritional status of children in India. The key indicators  of child nutrition - stunting (low height for age), wasting (low weight for height), underweight (low weight for age) in children below 5 years of age show a dip suggesting acute or chronic child under-nutrition.

This is in line with the 2020 Global Hunger Index, which shows that India falls under ‘serious hunger’ category, with 14 percent of the population being undernourished.

What does the data reveal?

Thirteen of the 22 states/union territories in the country show a rise in stunting. The highest rise in stunting is in Meghalaya at 46.5 percent followed by Bihar at 42.9 percent, although Bihar shows an improvement from 48.3 percent in 2015-2016.  Sikkim shows the lowest stunting at 22.3 percent with a 7.3 percent decline since 2015-16.

The rise in stunting for Goa at 25.8 percent and Kerala at 23.4 percent is worrying since both the states were the lowest in NFHS-4 survey, say authors Neeraj Kumar and Arup Mitra (2021) of the Working paper titled 'What causes poor child health in India? Reflections from NFHS-5' published by the Institute of Economic Growth.

Sixteen of the 22 states show an increase in the proportion of underweight children below age 5 in 2019 as compared to 2015. These include Nagaland, Himachal Pradesh, Kerala and Telangana. Child wasting too has become worse in 12 of the 22 states/UTs. Maximum increase in the level of child wasting has been found in Ladakh, followed by Nagaland and Jammu and Kashmir while Karnataka shows maximum improvement.  

The data also shows an increase in proportion of overweight children under 5, which has not been discussed in any of the current discourses on child health, but also needs attention.

Iron deficiency anaemia among children shows an increase from 59 percent to 67 percent in the last five years. Gujarat among the larger states and other states such as Madhya Pradesh, Rajasthan, Punjab, Haryana, and Telangana which shows a prevalence of more than 70 percent anaemia among children. The increase in the prevalence of anaemia is the greatest for Assam, while four states namely Uttarakhand, Haryana, Jharkhand and Meghalaya show a marginal reduction in anaemia.

Experts highlight that these deteriorating signs of decline in child health might have to do with economic slowdown, deteriorating public health care systems, or due to adverse effects of poverty, unemployment and the economic shocks that India experienced during the pandemic.

Neeraj Kumar and Arup Mitra (2021) state that a careful examination of NFHS-5 data shows considerable improvement in close to 100 of the 131 indicators associated with child health such as falling mortality rates, improvements in sanitation and hygiene facilities, improved breastfeeding and dietary patterns among infants and toddlers, higher immunisation coverage, better utilisation of maternal care facilities and increased government support in terms of utilisation of insurance and financing scheme.

Consumption of nutritious food - on the decline?

So where does the problem lie then? Neeraj Kumar and Arup Mitra (2021) argue that this might have to do with the possibility that the consumption of nutritious food is on the decline as poor households might be cutting down on quantity and quality of food  while better off households might have increased spending on consumption of junk food.

Seetha Anitha et al in their paper titled 'Can feeding a millet-based diet improve the growth of children?—A systematic review and meta-analysis' published in the journal Nutrients inform that although several factors affect growth among children, diet is a major factor which cannot be neglected. Nutrient deficient diets can hinder children’s short and long-term physical, mental, and emotional development, and consequently the economic and social development of the country. Undernutrition  increases the risk, frequency and severity of infections among children.

Diversified diets – the way out?

Muthamilarasan and Prasad (2021) in their paper titled 'Small millets for enduring food security amidst pandemics' in the journal Trends in Plant Science argue that at times, abnormal or crisis situations can trigger over-reliance on a small number of major cereals. The ongoing COVID-19 pandemic could also have presented challenges to the lives and livelihoods of marginal communities by limiting their access to food and overdependence on cereals to meet their needs.

One of the ways to address food insecurity and ensure preparedness to future catastrophes is to mainstream the production of crops that are marginally cultivated in arid- and semi-arid regions and grow well inspite of limitations faced due to poor soil fertility, rainfall, are resilient in the face of pest attacks,  provide good market value, taste and texture, and have reduced requirements for agricultural inputs.

And small millets provide the answer, inform Muthamilarasan and Prasad (2021). Small millets or minor millets can serve as a great source of food and nutritional security and help the poorest and most vulnerable segments of the population during situations such as the current pandemic to meet their food requirements.

Small millets are superior to major cereals in terms of agroecological traits, nutritional quality, and ensuring food security. They are extremely efficient in terms of water and nitrogen use and can survive even in water limiting conditions. Small millets are also rich in micro- and macro-nutrients, total protein, fibre, and resistant starch.

Small millets have a number of advantages over major cereals:

• They ensure subsistence and income to the marginal population because of minimal yield loss due to climate, rainfall, and diseases and better gross returns.
• They help to make agriculture sustainable due to reduced dependence on synthetic fertilisers, pesticides, weedicides, and insecticides.
• The carbon footprints of small millets are lower than those of major cereals
• Small millet cultivation and use decrease the over-reliance on major cereals that are limited in number.
• Millets are known to be highly nutritious with no compromise in taste and texture and can greatly contribute in ensuring diversity in food.

India is making efforts to include millets back into the diet and the Government of India has launched the National Millet Mission in 2018 and celebrated that year as the ‘National Year of Millets’. The National Institution for Transforming India (NITI) Aayog has announced a pilot to include millets in the Integrated Child Development Services (ICDS) and Mid-Day Meal (MDM) schemes across the country. The year 2023 has been approved by the United Nations as the International Year of Millets.

Previous studies show that regular consumption of millets can help in reducing the risk of type 2 diabetes, hyperlipidaemia, hypertension, and body mass index (BMI), thereby helping manage cardiovascular disease risk, improve haemoglobin level, and reduce anaemia, as well as helping calcium retention.

However, very few studies have highlighted the role of millets in improving growth patterns among children to help  prioritise these crops in nutritional interventions.

Seetha Anitha et al (2021) present the findings of their study which collates and analyses evidence on the benefits of using millets in improving the growth of children. The analysis finds that there was a significant positive effect of replacing rice with millet in regular diets of infants, preschool and school going children, and adolescents on height, weight, MUAC, and chest circumference -indicators showing growth patterns among children. These positive effects of millets can be attributed to the naturally high content of growth promoting nutrients (especially sulphur amino acids, total protein, and calcium in case of finger millets), given that the rest of the diet was similar between two groups, argues the study.

The study provides evidence that millet-based diets can be effective in improving height and weight where regular rice-based diets are currently consumed. Thus, changes at the policy level should include:

• Nutrition intervention programs to diversify staples using millets.
• School feeding programs, and mother and child programs that  incorporate millet based meals designed for different age groups, using culturally sensitive and tasty recipes.
• Complement these interventions with awareness and marketing campaigns to change the image of millets to increase demand and encourage investments in millets along the value chain - from fork to farm.