Opinion

Combat child undernutrition more effectively

| Updated on: Nov 29, 2021
image caption

Cereals, pulses and oils must also be included to the PDS food basket, in ‘nutrition high risk’ families

The Global Hunger Index (GHI), published annually by Concern Worldwide and Welthungerhilfe, tracks hunger at the global, regional, and national levels, including presenting intra-country comparison. This year’s index places India at 101st place, down from 94th in 2020. An uproar has been raised over India’s drop in ranking between 2020 and 2021 but this interpretation is incorrect. The report states clearly that “rankings from one year’s report cannot be compared with those from another year” and provides reasons.

The Indian government calls the GHI methodology ‘unscientific’, and they are right. At first glance, the ranking appears shocking. A closer look into the methodology and calculation process, as well as interpretation, reveals many red flags. The four key indicators – on the basis of which the GHI is compiled – namely, undernourishment, child wasting, child stunting and under-five mortality, do not capture the hunger situation and the nomenclature is misleading.

Hunger is recognised as a form of food deprivation. These GHI indicators measure undernutrition but not hunger. Hunger is one of the primary determinants of malnutrition, but not the sole cause. We cannot ‘equate’ hunger with child undernutrition. This highlights the inherent problems in the terminology used for the index.

Another question relates to the source of data used to generate annual GHIs and why annual reports are published. Under-five mortality data for India is available at the national level, but not annually. Child stunting and wasting data for 2005-06 and 2016-17 is available from the National Family Health Survey (NFHS-4&5) and are comparable, but the 2019 Comprehensive National Nutrition Survey (CNNS), which may have been the source of the latest GHI, is not comparable to NFHS. This is because the methodology differs and covers children in the 1-4 age bracket and not under five.

Unclear assessment method

The method of assessing ’undernourishment’, the population with a calorie deficit, is rather unclear. An extensive diet survey including calories and other nutrients was conducted in 10 States in 2012 by the National Nutrition Monitoring Bureau, but calorie data has not been collected since then. This raises the question – where is the data on undernourishment’ that accounts for a third of the overall GHI ranking, coming from?

The FAO, it is claimed, relied on data for ’undernourishment’ from Gallup surveys due to the pandemic, which has a number of limitations and is problematic. In a country as large and diverse as India, selecting the sample, is crucial. Moreover, without knowing the details of the survey (States surveyed, questions asked) or any other methodology used, it is impossible to be certain how representative the assessment is. It may be argued that these kinds of problems would affect other countries as well. This needs to be examined since the possibility of bias and errors in a Gallup survey would be possibly affected to a greater extent by differences in population size and intra-regional differences. Such a method would overestimate or underestimate ‘undernourishment’ score and impact ranking.

In 2018, I raised these concerns with Professor Arun Nigam, a nationally renowned statistician, who questioned the GHI’s methodology in a peer-reviewed journal, leading to the ICMR Expert Group’s discussion in 2019-20 of the matter. According to Dr Padam Singh, Chairperson of the Expert Group and Dr Nigam, member, “GHI exaggerates the measure of hunger, lacks statistical vigour, and has a problem of multiple counts. The present measure has no focus and standing and is misleading. The GHI, therefore, must be discontinued without delay for comparing hunger status of different countries".

Alarming status

The GHI report, however, highlights the child nutrition situation in various countries and indicates India’s alarming status. This cannot be ignored. Over one-third of children suffer from chronic undernutrition, while a fifth suffer from acute malnutrition. Child undernutrition remains a grave persistent problem that needs serious attention. Considering that one-fifth of children in households with the highest wealth index are also stunted, or suffer from chronic undernutrition, we need to think beyond hunger. Considering that under-five children with low birth weight and poor weight gain are associated with a high rate of wasting in their first six months of life, when they receive 100 per cent of their nutrition through breastfeeding, it is evident that determining factors of undernutrition are broader than hunger alone. Undernutrition in India is primarily caused by poor infant and young child feeding practices combined with the fact that many children are born undernourished. Poverty, low level of women’s education, poor water and sanitation, and inadequate health services are among the underlying causes. Over-dependence on cereals eases hunger, but does not address undernutrition. Children aged six months and older should be given a diversified diet, including pulses, vegetables, milk, eggs, oils, etc. in addition to breastfeeding. Women should be well nourished and healthy before entering pregnancy.

Government efforts to ensure citizens don't go hungry during the pandemic are commendable. But we cannot overlook India's poor situation in terms of child undernutrition as presented in the GHI report. We must act urgently to reduce child undernutrition. Besides cereals, pulses and oils must also be included in the PDS food basket, especially for ‘nutrition high risk’ families with pregnant women and children under two. Milk, vegetables, and eggs must be affordable for adequate consumption. It calls for greater investment in supporting dietary diversity measures and behavioural change communication with priority to be given to preventing stunting during the first 1,000 days of life – 270 days of pregnancy and the first 730 days of the child's first two years when stunting is most likely to occur and is largely irreversible. Special attention should be given to the nutritional status of the mother, exclusive breastfeeding in the first six months, and proper complementing of breastfeeding with semisolid foods at around six months.

We should not let the Global Hunger Index ranking drag us down, but rather use it as motivation to combat child undernutrition more forcefully and with adequate budget through the ongoing Mission POSHAN 2.0.

(The writer is Founder Director, Public Health Nutrition and Development Centre, New Delhi. Views are personal)

 

Published on November 30, 2021

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