Only 23% of children aged 6-23 months received an adequately diversified diet, according to the study by Sutapa Agarwal from Tata Trusts, Rockli Kim and S V Subramanium from the Harvard Center for Population and Development Studies of Harvard University, and others, published in the European Journal of Clinical Nutrition in February 2019.

Among the poorest households, 18% of children had a sufficiently varied diet as compared to 28% of children from the richest households, a difference of 10 percentage points. At the same time, 17% of children of mothers with no education ate an adequately diversified diet as compared to 30% of mothers with a high school or higher education, a difference of 13 percentage points, the study found.

An “adequately diversified diet” entailed consuming at least four items from seven food groups used for the purpose of the study–grains, roots and tubers, legumes and nuts, dairy products, flesh foods (meat), vitamin A-rich fruits and vegetables, and other fruits and vegetables.

Eating a varied diet is as important, if not more, than the quantity and quality of nutrition. In the study, most children had a higher consumption of grains and a poor consumption of fruits and vegetables, nuts and legumes, eggs and meat.

“More than animal versus plant–we need to think of macro nutrients related to the balance between fat, protein and carbohydrates,” said Subramaniam, one of the co-authors of the study, in an email. “And for young children fat intake is critical. There is an emerging recognition to focus on proteins, but not nearly enough for fat intake among very young children. And here is where dairy consumption–including milk–is important for addressing the burden of child undernutrition.”

Wealth and education gap

“For the poorer strata it is affordability and accessibility, while for the better-off strata it could be lack of knowledge,” said Subramaniam, explaining the study’s findings. Food is an industry now, he said, adding that dietary preferences among the well off need to be interpreted in the larger context of global trends towards homogenous food.  

Home to almost a third of the world’s stunted children under five (46.6 million), India is not on track to reach the World Health Organization’s 2025 global nutrition targets, IndiaSpend reported in January 2019.

Of Indian children under two years of age, 90.4% did not receive an adequate diet, the National Family Health Survey-4 (NFHS-4) 2015-16 found. Some 18% of children aged 6-23 months ate iron-rich foods, and more than half the children in this age group were anaemic. About 54% consumed vitamin A-rich foods, the lack of which can lead to childhood blindness and poor immunity.

The present study on dietary diversity also used NFHS-4 data, in which mothers were asked to choose from a list of 21 food items they had given their children in the preceding 24 hours.

The items were then divided into seven food groups: grains, roots and tubers, legumes and nuts, dairy products, flesh foods, vitamin A-rich fruits and vegetables, and other fruits and vegetables.

The mean score of dietary diversity of Indian children was found to be 2.26, on a 0-7 scale, where 0 means children are not fed any of the 21 food items and 7 means they are fed at least one from all seven groups.

The biggest difference between children of different wealth groups was in consumption of dairy products–children in the richest households were three times more likely to consume dairy products as the poorest households.

Meanwhile, children of mothers with high school or higher education had a greater likelihood of consuming all seven food groups and had twice the odds of eating an adequately diversified diet as those with mothers with no education.

Grains consumed most

Among the seven food groups, children mostly ate grain–74% were reported to have consumed roots and tubers, 55% dairy products, 37% other fruits and vegetables, and 29% vitamin A-rich fruits and vegetables.

Children’s consumption was the lowest for eggs (14% of respondents), legumes and nuts (13%), and flesh foods (10%), the study found.

Between the richest and poorest households, the difference in consumption of dairy products was the highest (39% in poorest households vs 72% in richest households), followed by vitamin A-rich fruits and vegetables (26% vs 33%) and other fruits and vegetables (34% vs 40%).

Consumption of dairy products varied most by mothers’ education level–44% for uneducated vs 73% for educated–followed by vitamin A-rich fruits and vegetables (25% vs 34%), and other fruits and vegetables (32% vs 43%).

Although dietary diversity increased in 2016 as compared to 2006, it was poor throughout and actually reduced in the upper two wealth groups (out of five). Despite the reduced gap, the upper groups consumed 2-4 times more diversified diets than those in lower groups.

Consumption of some food items was influenced more by maternal education than household wealth. These included: pumpkin, carrots, squash, dark green leafy vegetables, liver, heart, organ meat, fish, shellfish, legumes and nuts, and flesh food.

Consumption of packaged items such as canned juices increased with increased wealth and mother’s education, which the researchers called “alarming”. They suggested that food items that are cheap in India such as pumpkin, carrots and dark green leafy vegetables should be encouraged.

Can more meat help?

To improve dietary diversity, children should be eating more animal-sourced foods. Indians consumed 194 gm and 242 gm of protein a day in rural and urban areas, respectively, against the recommended 459 gm, according to an analysis published in Livemint in January 2019.

Although dairy and poultry foods are cheaper in India than in some low- and middle-income countries, they remain beyond the reach of many. Here, cash transfers can play a role, said a study on child feeding practices in 2006 and 2016 conducted by the agriculture research group International Food Policy Research Institute (IFPRI) and published in the journal Maternal and Child Nutrition.

It would also be important to remove cultural barriers to meat consumption among young children, the study said. Among the one-third households that did not consume animal protein,  improving consumption of legumes/nuts and fruit and vegetables could help, said Phuong Nguyen, a co-author of the IFPRI study, on email.

Another study from IFPRI had found that despite health and nutrition education increasing three-fold from 3.2% in 2006 to 21% in 2016, the poorest mothers had the second worst coverage of health and nutrition services (after the richest group), IndiaSpend reported in March 2019.

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend

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Karnataka has the highest maternal mortality ratio in south India. The state is trying to combat it with a programme called Mathrupoorna, which provides nutritious meals, counselling and other health facilities to pregnant and lactating women at anganwadi centres. Here, Rupa Manju of Maladahadi village in Mysuru district, who is eight months pregnant with her third child and a Mathrupoorna beneficiary, gets a health check.

In 1975, when the Indian government launched the Integrated Child Development Services (ICDS), Karnataka was one of the first beneficiaries. The programme tackled maternal malnutrition and morbidity by providing mother and child with supplementary nutrition, immunisation, health check-ups and referral services on nutrition, health education and pre-school education.

Yet, in 2015-16, after four decades of ICDS, Karnataka had the highest maternal mortality ratio (MMR, which measures mothers’ deaths per 100,000 live births) among all the states in southern India–108.

It also had a high rate of stunting (low height for age) and wasting (low weight for height) in children under the age of five–more than a third (36%) of its children were stunted and more than a fourth (26%) were wasted, according to the National Family Health Survey 4, 2015-16 (NFHS-4), the latest available data.

To improve the situation, Karnataka launched the Mathrupoorna scheme in 2017 to fulfil the nutritional needs of pregnant and lactating women.

Similar to ICDS, Mathrupoorna seeks to meet the nutritional needs of pregnant and lactating (till six months post pregnancy) women.The difference being: while ICDS gave the beneficiaries dry rations once a month, Mathrupoorna offers them nourishing hot meals, six times a week. The meals are served at 65,911 anganwadi centres across the state. Women in their ninth month of pregnancy or 45 days post-delivery can have their meals picked up from the anganwadi.

In two years of operation, Mathrupoorna has reached 75% of its target population, according to Karnataka’s women and child development department (WCD), at an annual cost of Rs 645 crore ($91.4 million).

A different approach

It is a hot summer afternoon, and 11 women–eight pregnant and three lactating–are gathered at the anganwadi in Shankarbande village in drought-hit Ballari district. Vandaramma, 62, who goes by one name only, joins the group with an empty steel tiffin box in hand. These women are here for Mathrupoorna.

Anganwadi worker Sulochana and helper Sumitra walk in with large aluminium pots of freshly cooked lunch. Sumitra places a clean steel plate in front of each woman, and Sulochana serves them hot rice, sambhar (south Indian curry consisting of lentils and vegetables) and payasam (a dessert made of rice or vermicelli, and milk). Sumitra informs the women that she has added spinach to the sambhar along with other vegetables to “make it more nutritious”. The women are also given chikki (a jaggery-and-peanut sweetmeat), a glass of hot milk and one boiled egg each. Those who do not like eggs get sprout-salad.

While the women eat, Sulochana packs Vandaramma’s tiffin box with the same meal. It is for her daughter who gave birth 15 days ago and is now resting at home.

Mathrupoorna beneficiaries at the anganwadi in the tribal Maladahadi village in HD Kote taluka (sub-district) of Mysuru district, on the border of the Nagarhole Tiger Reserve. The wholesome meals provided to pregnant and lactating women six times a week take care of 40-45% of their daily calories, protein and calcium intake.

Inspired by similar nutritious meals programmes in Andhra Pradesh and Telangana, Mathrupoorna meals take care of 40-45% of the daily calories, protein and calcium intake of the target group. Mathrupoorna also focuses on the administration of iron and folic acid tablets, deworming, tetanus injection, gestational weight monitoring and counselling of the women.

The ICDS supplementary nutrition programme, which ran earlier, gave pregnant and lactating women and children up to three years of age 1,300 gm of a rice-and-soya mix, 1,200 gm of a wheat-and-soya mix, 900 gm of Bengal gram, 460 gm of green gram and 1 kg jaggery. Though this made up for some of the nutrition gaps, the rations were often shared by other family members. Sometimes the provisions were inadequate or pilfered. Under Mathrupoorna, since women must visit the anganwadi to eat, the aid reaches them in its entirety.

The Mathrupoorna scheme aspires to reach around 1 million (1,023,956) women in the state. Currently, it aids 772,104 pregnant and lactating mothers (including anganwadi workers and helpers who are also beneficiaries), according to the WCD, which implements the programme.
The central and state governments share the cost of the meals, which works out to Rs 21 per meal. While ICDS chips in with Rs 9.50 per meal, the rest is provided by the Karnataka government. “The cost of implementing Mathrupoorna may seem high. However, the cost of inaction is much higher,” said Uma Mahadevan, former principal secretary of WCD.

In February 2017, WCD launched a Mathrupoorna pilot project in four talukas of Karnataka–Manvi in Raichur district, HD Kote in Mysuru, Madhugiri in Tumkur and Jamkhandi in Bagalkot. “The money for the pilot project came from the department’s savings,” said Mahadevan. On October 2, 2017, the state government scaled up the programme to cover the entire state. Mahadevan played a crucial role.

Disturbing facts: stunting and wasting in children

The first 1,000 days of life comprise a unique period of opportunity when the foundations of optimum health, growth and neurodevelopment across the lifespan are established, according to the World Health Organization. “To tackle malnutrition, addressing nutritional needs in the first 1,000 days of life is important,” said Abid Ahmed, a UNICEF consultant assisting Karnataka’s WCD in the implementation of Mathrupoorna.
Stunting in children under five years of age is also worrisome in Karnataka (See graph 1: Nutrition status of under-five children in Karnataka)–36% of its children are stunted and 26% are wasted, according to NFHS-4 data. Between NFHS-3 (2005-06) and NFHS-4 [2015-16], children suffering from wasting and severe wasting have gone up in the state, which is a matter of high concern, said Ahmed.
Regional disparity in stunted children is also stark. (See map 1: District-wise ‘stunting’ in under-five children in Karnataka).

District-wise Stunting In Under-Five Children In Karnataka

“Child stunting in Karnataka is a concern. In 2013, the state government launched the Ksheera Bhagya scheme to provide hot milk (150 ml per child per day) to all the children in anganwadis and government schools thrice a week. This was increased to five times a week in 2017-18, providing valuable calcium, protein and other nutrients,” said Mahadevan. Also, anganwadi children are given eggs twice a week. Eggs provide high-quality protein and choline (essential for the structural development of the body), necessary for young children.

The comfort of a hot meal

“Daily wage labourers like us cannot afford to have milk and eggs,” said Vandaramma at the Shankarbande anganwadi, who belongs to a scheduled caste (traditionally “lower” caste). “Even family members will not feed us if we do not go to work and earn a living.”

Mamtha G is nine months pregnant but continues to visit the anganwadi in Tungoti village in Madhugiri block of drought-hit Tumkur district. Apart from the hot meals, it is also the chance to “step out of the house and interact with other women” that draws her to the anganwadi every day.

Meeting other women at the anganwadi also helps deal with postpartum emotional upheavals, she said. Her first child is two-and-a-half years old.

Sudha Ramesh is the mother of a one-and-a-half-month-old baby and is also a regular at the anganwadi. “In our homes, post-childbirth women are offered only rice and watery sambhar; nothing else. At the anganwadi we get vegetables, eggs and hot milk,” she said.

More than 250 km away, similar voices emerge at Maladahadi village in HD Kote taluka of Mysuru district, which lies on the border of the Nagarhole National Park and Tiger Reserve, and is home to the Jenu Kuruba tribe.

Yamuna Ramesh is a native of the village and was registered under the Mathrupoorna scheme from the beginning of her pregnancy. One month back, she gave birth to a healthy baby girl weighing 3 kg. “Traditionally, we eat only two meals a day; rice and sambhar in the morning and ragi [finger millet] balls in the evening,” she said. At the anganwadi, the young mother gets eggs, her favourite, and also leafy vegetables.

Anganwadi workers regularly monitor pregnant women like herself for weight gain and mid-upper-arm circumference to check for malnutrition. “We counsel the tribal women to consume lentils and vegetables,” said anganwadi worker Rukmini.

Apart from providing hot meals to pregnant and lactating mothers, Mathrupoorna also focuses on the administration of iron and folic acid tablets, deworming, tetanus injection, gestational weight monitoring and counselling. Here, the anganwadi worker measures a beneficiary’s mid-upper-arm circumference to check for malnutrition.

The challenges

Although Mathrupoorna covers 75% of pregnant and lactating women in Karnataka, there is a wide variation in district-wise coverage. For instance, in Bagalkot district, it is 92%, whereas, in Dakshin Kannada district, it is 27% (See graph 2: District-wise coverage under Mathrupoorna).

Source: Department of women and child development, Karnataka

“The difference in coverage reflects the divergent needs and socio-economic contexts of various districts,” said Mahadevan. “Karnataka has significant regional differences in poverty levels and human development indicators among its districts.”

Other stumbling blocks include seasonal migration for work.

A large number of women at the anganwadi in Ibrahimpura village, Ballari taluka, where Bashira has worked for the last five years, are daily wage farm labourers. Seven pregnant and four lactating mothers are enrolled under Mathrupoorna here. Child stunting and malnutrition are high in this region of north Karnataka, and mothers are malnourished. “In the summer, the enrolled women, along with their families, migrate to Bengaluru in search of work and often fall out of the anganwadi network,” said Bashira.

To prevent such exigencies, Karnataka government has introduced Thayi cards (mother’s card/a mother and child registration booklet) for pregnant and lactating mothers, which can be used in any district to avail the benefits of Mathrupoorna. However, more often than not, poor women are unable to do so.

There are daily wage earners like eight months pregnant Laxmi, a resident of Shankarbande village, Ballari, who do not get the full benefits of Mathrupoorna. Laxmi leaves home at seven in the morning and returns only around five in the evening. As a farm labourer, she earns Rs 200 a day; men earn Rs 300. “It is not possible for me to leave work mid-way and go to the anganwadi to eat,” she said. She visits the anganwadi on rare occasions when she is not at work.

Social taboos, migration and varying poverty levels are major stumbling blocks for Mathrupoorna. However, one obstacle is overworked and underpaid anganwadi workers. The government programme has increased the burden of anganwadi workers and helpers, according to health sector activists.

Culture and social stigma also prevent women from using the programme. “The local culture does not allow a pregnant woman to step out of the village until she completes five months of pregnancy. So, if the anganwadi is slightly far away, the family does not send a pregnant woman,” informed Bashira. In other areas, sending a pregnant woman to the anganwadi for a meal becomes a “prestige issue”. In Shankarbande village, there are three pregnant women and two lactating mothers who have never visited the anganwadi. “In spite of counselling, their families don’t approve of it,” said Sulochana, an anganwadi worker.

“There is no doubt that decentralised kitchens that serve hot meals and provide basic access to nutrition are welcome. In that sense, Mathrupoorna is a good programme,” said Sylvia Karpagam, a public health doctor and researcher from Bengaluru. “But, there are implementation issues that overburden anganwadi workers and helpers, and exclude some women due to poverty and caste factors.” Anganwadis are primarily child care centres. Mathrupoorna has put an additional burden on anganwadi workers and helpers, Karpagam said. “They spend too much time cooking and serving meals and in the process anganwadi children get neglected. The workers are also underpaid.”
To ease the burden on the workers, the government has provided twin-burner stoves, additional LPG cylinders, pressure cookers and large cooking vessels to anganwadis. “So that the helpers do not spend too much time cooking,” said Mahadevan. The monthly salary of anganwadi workers and helpers has been raised from Rs 4,000 and Rs 3,000 a month to Rs 8,000 and Rs 4,000, respectively. “They also receive Rs 50,000 medical reimbursements,” Mahadevan said.

However, anganwadi workers have demanded better compensation for frontline workers–Rs 18,000 per month for anganwadi workers and Rs 12,000 for helpers.

The success of any such large-scale health programme depends on the frontline staff, Karpagam said. In case of Mathrupoorna, there are 64,800 anganwadi workers and 60,207 anganwadi helpers implementing the programme even in the remotest parts of the state, including inside forest areas. Adequate compensation and regular training of these is vital for further increasing coverage of Mathrupoorna, she added.
 

(Nidhi Jamwal is environment editor with Gaon Connection.)

Courtesy: India Spend

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