Tackling the problem of nutrition

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While health was not a priority for Budget 2025, it seems that nutrition is. In the coming financial year, two Union government schemes will receive higher allocations — Saksham Anganwadi and Poshan 2.0. But will this fix India’s nutrition challenge?

Nutrition in India is not just about food insecurity, but also about dietary habits shaped by culture, caste, and gender relations. Only one aspect of the nutrition challenge receives most of the policy focus — malnutrition among women and children. Women outside of the reproductive age, men, and senior citizens rarely figure in national nutrition policy discussions. More importantly, we ignore diabetes, hypertension, and other lifestyle-induced non-communicable diseases which are really another manifestation of under nutrition. One type of nutrition deficiency is because some people just don’t have enough to eat and the other type is because people are not eating sufficient nutritionally rich food. The outcomes are damning in unique ways.

India has among the world’s highest share of malnourished children and anaemic women. According to the National Family Health Survey-5, 36% of children under five are stunted and a meagre 11% who are breastfed between the ages of 6 months and 23 months receive an adequate diet. Fifty-seven percent of women in the 15-49 age group are anaemic. There is a rise in the share of those with diabetes, hypertension, and other such lifestyle-diet induced non-communicable diseases (NCDs). 24% of women and 23% men in India are overweight or obese and 14% take medicines for diabetes.

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A comprehensive agenda

Poshan 2.0 and Saksham Anganwadi offer more of the same solutions — take-home rations, supplementary foods, tracking of severe and acute malnutrition cases, iron and folic acid tablets etc. With Poshan 2.0, there is additional focus on aspirational districts and the north-eastern region. But these schemes reinforce the idea that malnutrition is a problem only in certain parts of India and only in certain segments of the population. Instead, what we need is a comprehensive nutrition agenda in which nutrition is identified as a public health problem that impacts people across the social strata.

A comprehensive agenda would recognise the nutrition needs of different segments of the society. It must consist of: first, a clear identification of nutrition needs beyond reproductive and child health; second, a broad set of solutions, particularly rooted in the local food systems; and third, a clear identification of locally embedded facilities to deliver nutrition services. We need most work in identifying local institutional linkage for the agenda. Who will implement this in our neighbourhoods every day? The clear answer is: the health and wellness centres (HWCs).

At present, we provide supplementary nutrition for pregnant and lactating mothers and young children through take-home rations, iron and folic acid tablets for adolescent girls at Anganwadi centres (AWCs); and mid-day meals for children in schools. We need to systematically expand the nutrition-focused activities to other segments of the population and involve HCWs and ACWs. The mix of nutrients which goes in the take-home ration for poor women is relevant for pregnant women from all strata of society. Food items which use locally available low-cost, nutrient-dense produce need to be emphasised for the middle classes too, which consume sugar-laden, fibre-poor packaged goods.

For HWCs to implement this agenda, they need to be in sufficient numbers to cover the entire population. Each of them has to have a detailed set of nutrition services covering the entire catchment population. At present, the spread of HWCs is lopsided. Rural areas seem to have them in excess when compared to urban ones. And within rural areas, some areas have a higher concentration of HWCs.

Nutrition services in HWCs are limited. HWCs are supposed to provide nutrition advice to pregnant women and lactating women, adolescents and children, the elderly population, and those recuperating from disease, disaster and trauma. But these are not implemented consistently or systematically.

We also need dedicated staff to provide nutrition services at the HWCs. In the existing design, nutrition is a tiny part of the responsibilities of the multi-purpose worker.

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Factors for success

The success of the nutrition agenda will depend on two factors: engaging with local elites; and linking nutrition practices with local cuisines. Professor Prerna Singh at Brown University demonstrates in her research on small pox vaccination that there was significant variation in the uptake of vaccination during the 1950s among equally placed countries such as India and China. Some got their population vaccinated earlier and faster than others. Those that did were countries where the vaccination interventions were publicly owned by local elites and connected with local health practices and ideas.

India is a rapidly transforming society. We have to push further with the HWC approach of imagining health as wellbeing and not just an absence of illness. A locally owned, comprehensive nutrition agenda for all strata of society delivered by the primary health system is a first step in this direction.