A new protocol for management of malnutrition in children released by Union minister Smriti Irani on October 11, 2023, acknowledges that nutrition plays a key role in health and development and is ‘one of the most important challenges facing contemporary India’.
Most of the strategies presented in the protocol seem to suggest a wait and watch approach till after malnutrition has set in. Unfortunately, as the protocol itself mentions, malnutrition can often have irreversible long and short-term consequences, even with interventions.
What is a holistic approach as promised by the Poshan Abhiyan?
The protocol mentions several determinants of undernutrition such as low income, large family size, gender bias, changing crop patterns, lack of knowledge, poor health etc. which lead to dietary imbalance, reduced access to food, loss of traditional food habits etc. Many of these determinants end up being attributed to communities and families, especially mothers. If the ‘holistic approach’ of the Poshan Abhiyan is to be realised in spirit and practice and in the interest of evidence based nutrition, all barriers to good nutrition – economic, social, political, cultural and religious should be objectively documented and addressed.
The protocol states that diet diversity should be followed when constructing diets for malnourished children and it is good that nutrient dense foods such as egg and whole milk have been included. Eggs, which contain important nutrients should ideally be given on all days of the week to all children and not to just to those identified with malnutrition. Those with religious, caste or health restrictions on eggs should be given an additional glass of milk or a bowl of yoghurt.
Although (on paper), people are encouraged to eat their ‘traditional foods’, very often these are made inaccessible to them because of economic, political or social reasons. Erasing and criminalising animal source foods consumed by many communities institutionalises caste and communal prejudices. This is very evident in India.
For example, organisations such as Akshaya Patra, which have bagged mid-day meal contracts in several states in India, take a belligerent, unscientific sattvik (anti-meat, anti-egg) stance which is a serious impediment, often intergenerational, to addressing malnutrition in the country.
So also, cattle slaughter bans, economic boycotts of Muslim communities, banning meat shops etc. adversely affects people’s access to nutrient dense foods and creates shame around these foods. The government’s ‘multi-pronged strategies’ of criminalising and/or erasing nutrient dense foods on the one hand while also pretending to hold the mantle against malnutrition, therefore reeks of dishonesty and duplicity.
Preventing rather than treating malnutrition should be the primary goal of any nutritional intervention programme. Children with stunting and undernutrition are likely to have a host of other nutritional deficiencies which make them susceptible to anemia, night blindness, cognitive deficiency, skin disease, respiratory, gastro-intestinal disease, etc. Viewed in that context, the rapid push for fortification by the government stands out as woefully inappropriate and unholistic. In a country with alarming hunger and multiple nutritional deficiencies, fortifying the nutrient-poor and over consumed cereals with one or two ‘micro-nutrients’ is neither economic nor a solution.
The Poshan tracker focuses inordinately on the Aadhaar card in spite of several concerns about it, pushing those most in need of social security to fall through the gaps. Aadhaar-verified beneficiaries are 9,55,73,667 (9.6 crore) out of 10,10,89,751 (10 crore) eligible beneficiaries, which means that only 94% are verified and 55,16,084 (0.55 lakhs) have been left out.
Even in aspirational districts and in the northeast region, of a total of 22,71,111 adolescent girls, only 18,71,228 (82%) are Aadhaar verified. Of these 3,22,807 have received take home rations. What is ‘holistic’ about leaving out vast sections of people, especially those most in need of social security?
The government thus seems to have a wishful desire (on paper) for an ‘overarching scheme for holistic nourishment’ through the Poshan Abhiyan, but in reality it is neither overarching nor holistic. Neither is it adequately nourishing.
Children in an Odisha school eat their midday meal. Photo: mdmodisha.nic.in.
No appetite for a test
The protocol lays emphasis on the appetite test to be conducted by the Anganwadi worker on children with Severe Acute Malnutrition (SAM) children using a hot cooked meal from the Anganwadi. Only those children who ‘fail’ this ‘test’ will be referred to the Nutrition Rehabilitation Centres (NRC), while those who ‘pass’ will be enrolled under the Supplementary Nutrition programme and referred to the primary health centre medical officer for assessment.
Earlier guidelines mandated that all children with SAM were referred to NRCs where, in addition to nutritious foods, medical and counselling support was also expected to be provided. This is one of the major changes that has been brought about in the new protocol.
However, the appetite test, which has been elaborated upon in the protocol, has not been found to be a reliable tool to identify at-risk children and categorise them as needing inpatient or outpatient care. A child may not feel like eating food if she has recently had a sore throat, fever, nausea or vomiting. It could be that the child does not like the smell or the taste of the food, is thirsty or is apprehensive about the teacher (or parent). The Anganwadi teacher is expected to screen for health issues, when, in reality, there can be no side-stepping the need for close interaction of the Women and Child department with the Health department for ‘holistic care’ of the child. Children need regular screening health checks to pick out common diseases so that they can receive timely care and this is non-negotiable.
Burdening the Anganwadi teacher
The new protocol for malnutrition has introduced several categories such as SUW (Severe Underweight), MUW (Moderate Underweight), SAM (Severe Acute Malnutrition), MAM (Moderate Acute Malnutrition) etc. based on World Health Organisation (WHO) child health growth standards. But these could confuse and overload the already overwhelmed Anganwadi worker who can get personally penalised for poor nutrition status of children as though it is an individual rather than system issue.
These workers are also expected to train families on WASH practices (safe drinking water, personal hygiene, hand washing, use of toilets, cleanliness of home and surroundings). According to the Poshan tracker statistics, there are a total of 13,96,957 Anganwadi centres, with only 11,01,843 having functional toilets, or 21% ( 2,95,114) Anganwadi centres without a functional toilet. It is a common sight to see children urinating and defecating outside the Anganwadi centres.
According to the same tracker, only 87.5% (i.e. 12,23,578) Anganwadi centres have drinking water. 1,73,379 Anganwadi centres therefore do not have drinking water. If each Anganwadi centre caters to around 40 children, it means that 69,35,160 children are exposed to unsafe water in the Anganwadi centres. Using unsafe (non-potable) water for drinking or cooking can lead to gastrointestinal disease, pushing the child into a vicious cycle of malnutrition and ill-health. If Anganwadi centres themselves do not have toilets and drinking water, how is it logical for these centres to offer training to mothers and communities about the importance of these?
Anganwadi workers, who not only cook food for children with help of an Anganwadi sahaiyka (helper), and double-up as a primary-level teacher, are also now expected to visit homes of children with malnutrition to provide health education and monitor progress. This is an unrealistic expectation unless arrangements are made for one teacher to handle the Anganwadi centre, while another makes home visits. Importantly, many of these Anganwadi teachers could carry the same food related misconceptions and prejudices as shared by their senior officials to the community, thus causing more damage than good.
Are millets really magical?
Millets, which are expected to be promoted through the Anganwadi, contain on an average 56-73 gm/100 gm of carbohydrate and none of the millets contain all the essential amino acids (EAA). The ‘high-fibre’ in millets can contribute to decreased transit time in the gastro-intestinal system and feeling of fullness or satiety after a meal, This can translate to feeling less hungry and eating less frequently which is not always desirable, especially in malnourished children.
The presence of ‘anti-nutrients such as lectins, phytates, tannins etc. can reduce the digestibility and absorption of essential nutrients from millets. Some of these unwanted effects can be reduced through germination, fermentation, pressure cooking, etc.
In the rush to push for millet once a week as suggested in the protocol, let us also not forget that many of these foods have a very cultural context. While some Kannadigas would drool over the chewy and sticky ragi mudde, it could be a potentially unpleasant experience for a person unaccustomed to it. Children could likewise be accustomed to certain tastes and textures. Pushing them to eat unusual foods because they are ‘healthy’, economical or good for the climate shows a certain insensitivity.
The ministry seems to be enamoured by an initiative from Assam where the mother of a healthy child becomes the ‘buddy mother’ to support the mother of a malnourished child, as per the new protocol. In reality, it would seem that a more responsive and responsible ‘buddy government’ is the need of the hour for children and families either struggling to come out of the vicious cycle of malnutrition or constantly being pushed into it.
Sylvia Karpagam is a public health doctor and researcher.