Leverage POSHAN 2.0 to address gaps in Under-5 child nutrition in India: Experts

New Delhi: It is well established that 68% of under-5 child mortality in India is associated with malnutrition, and over one third of under-5 children in the country is chronically undernourished or stunted. An insight into child nutrition situation and determinants, revealed by the fifth National Family Health Survey (NFHS-5) 2019-20 for 22 States and Union Territories (UTs), is of extreme concern.

A rapid trend analysis report, published by the Observer Research Foundation (ORF), compares findings of NFHS-4 (2015-16) and NFHS-5. The report, authored by Dr. Sheila C. Vir and Dr. Shoba Suri, finds a reversal in the progress made on some of the key nutrition indicators in the country. These include an increased trend in chronic undernutrition (measured as stunting or height for age) in 13 States, as well as a rising trend in the percentage of overweight under-5 children in every State with the exception of one UT. The unexpected increasing trend in undernutrition in States such as Kerala, Goa and Himachal Pradesh where over 60% women are reported to having completed at least 10 years of education is intriguing and has been analyzed.

Child undernutrition is broadly determined by underlying and immediate factors. Data reveals that the underlying determinants that are most crucial for preventing chronic child undernutrition or stunting are women’s education, height not less than 145 cms and right  age of conception  as well as improved antenatal care services and water-sanitation-hygiene (WASH) situation The percentage coverage of nutrition-sensitive interventions focusing on underlying determinants – comprising the status of women’s empowerment, health care of women, and WASH practices – have seen positive trends in the period of four years, between 20154 and 2019. As per the latest NFHS-5 data, relatively more women today have access to safe and clean sanitation facilities, maternal health services and institutional delivery, possess their own personal mobile phones and bank accounts, and are able to stay in school for longer and delay conception till after they turn 18. Women owning mobile phones, and having bank accounts and access to clean fuel, considered by authors as proxy indicators of women’s empowerment, show an unusually high coverage of over 60 percent in more than half of the States and UTs and 9 states reporting over 80 percent. The effective and accelerated implementation of national programmes in the recent past, such as Jan Dhan Yojana, Janani Suraksha Yojana, Swachh Bharat Abhiyaan, Ujjawala Scheme, and Beti Bachao Beti Padhao mission, among others, have been integral to enabling such progress.

Why are child nutrition indicators not reflective of this progress?

The progress noted in underlying determinants in themselves are insufficient to address the problems of undernutrition. While they indirectly impact the immediate determinants, it is imperative to simultaneously address and expand the scope of interventions to directly address the immediate determinants. The latter include appropriate diet and infant and young child feeding (IYCF) practices as well as child health services. IYCF comprises breastfeeding and complementary feeding (CF). CF refers to shifting from exclusive breastfeeding for the first six months of life to introduction of semi- solid food items to a child along with the continuation of breastfeeding. Appropriate CF comprises selection of the right food items from at least 4 diverse food groups, combined with continued breastfeeding and feeding adequate quantities of food 3-4 times a day.

The ORF report highlights that CF practices continue to be insufficient, possibly contributing to the child undernutrition situation. Unaffordability does not appear to be the sole cause for poor CF practices. This is supported by the fact that as per NFHS-4 findings, 20% children in the highest wealth index were also reported to be stunted. Lack of awareness to make the right food choices from appropriately diverse food groups, and caregivers not having adequate time to follow the recommended feeding practices as well as attraction to use meagre resources in commercial attractively packaged foods are argued to be the central cause of child undernutrition. A family will accord priority to appropriate CF only if made aware of the serious consequences, i.e. largely irreversible impact not only on physical growth, but also on brain development. Moreover, generating awareness to address the rampant incorrect perception that an undernourished child is emaciated looking is crucial for ensuring that the ‘not visible’ but damaging problem of chronic undernutrition is not overlooked.

What are the policy needs?

The first 1000 days of life. from onset of conception to 24 months age, are identified by experts as crucial to ensure optimal growth. 80% of the brain development occurs in this window, providing the opportune timeframe for investing in child nutrition, they argue. Any family with a pregnant woman or a child 0-24 months needs to be viewed as a family at high risk of child undernutrition. Timely efforts need to be specially directed at these families. Even though several nutrition-sensitive interventions and maternal and child health care services as well as to some extent breastfeeding practices have improved, CF practices remain largely neglected. This provides an opportunity for the upcoming POSHAN 2.0 to fill this gap and create an enabling environment for the adoption of appropriate IYCF practices and moving beyond mere supply of supplementary nutrition or Take Home Ration (THR). Both food and feeding practices matter.The authors additionally make the case for community level mapping of households with pregnant or newly married women and children between 0-24 months of age. A convergent multi-sectoral system comprising the Health Department, Integrated Child Development Services (ICDS), Public Distribution System (PDS), WASH and the National Rural Livelihood Mission (NRLM) must aim at reaching these households regularly with information and services to address underlying and immediate determinants of young child nutrition.

The ORF report identifies the need to employ effective social and behavior change communication (SBCC) to address misinformation and empower women and families to make the right affordable and locally applicable food choices to address all the three primary problems of child malnutrition – undernutrition, overweight or obesity and micronutrient deficiencies.

The recommendations put forth in the report include a plea for intensified advocacy efforts prioritizing investment in child nutrition and placing it high in the development agenda. There is also a need for the New Education Policy to incorporate nutrition education for children on ‘eating right’. FSSAI’s Eat Right policy is a step in the right direction. It needs to be further strengthened to improve overall family eating habits and to prevent the emerging problem of overweight which seems to be more rapidly rising particularly in states with a higher percentage of women with minimum 10 years of education. Greater emphasis also needs to be laid on use of fortified food items and ensuring timely supply and consumption of vitamin A and iron-folic acid supplements that are being supplied through the government health system.

Malnutrition is known to affect the cognitive development and future earning potential of children. It also impacts the nation’s Gross Domestic Product (GDP), human capital and 13 of the 17 Sustainable Development Goals (SDGs). To ensure reduction in chronic child undernutrition (stunting) and prevent adverse impact on growth and lifelong development of a child, the report calls for serious efforts to intensify measures for meaningful multi-sectoral convergence at family level of under twos for improving child feeding practices coupled with maternal nutrition care as well as measures for food and nutrition security and WASH services, and making appropriate complementary feeding  practices a Jan Andolan (people’s movement) for intensive public involvement.