Commentary

Weighing the paradox of undernutrition and fat

Shweta Khandelwal, Giridhara R Babu & Anura V Kurpad

doi:10.1038/nindia.2018.168 Published online 19 December 2018

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The decline of India’s rate of undernutrition is stubbornly slow, while numbers of people who are overweight and obese are soaring. Its population is transitioning from one group to the other alarmingly quickly, with few in a state of optimal nutrition.

Too many of its young population suffer from chronic diseases that would not be expected until middle age in other parts of the world. Only one in ten children between six and 23 months of age has an ‘adequate diet.’ One in three preschool children is malnourished and the proportion of urban overweight children is increasing.

The nutrition imbalance has knock-on effects for the environment, and for the economy, and wealth generation. For example, the swift increase in obesity rates in India has been fuelled by the low cost of simple sugars and unhealthy fats, while healthy foods like fruits and vegetables are not readily accessible. India has implemented almost every possible policy to improve the state of nutrition and alleviate poverty. These range from micronutrient supplementation and the provision of cooked food, to subsidized cereal grain for poor and vulnerable segments of the population.

However, there has been a systemic failure of implementation. For example, there has been a more than threefold increase in food grain procurement by the government during the past two to three decades, yet inefficiencies in storage and distribution has resulted in the inadequate supply of grains to those in need, leading to the extraordinary paradox of rotting of food grains amidst widespread hunger.

Substantial scope remains for implementation and advocacy research in nutrition, focusing on the complex operational problems arising from efforts to alleviate poverty and malnutrition. Sound research should inform successful policies, but good governance and coordination is needed to put those policies into action.

For example, the provision of subsidized nutritional food might appear to be a clear and simple task, but the responsibility for it is fragmented. Child development, maternal and child health, and education are located in different ministries, which do not always work together.

Political will, ownership and decentralization are critically important for ensuring nutrition through the life course.

It can be difficult to turn science into policy. Evidence generation has come to demand the rigour of a randomized controlled trial. However, the randomized controlled trial design does not lend itself easily to the multiplicity of nutrients in food or the complexities of food production, access, and consumption. Frameworks that reduce foods to nutrients, offer one way to overcome this problem. But they might also oversimplify complex processes and eventually, form a distraction to the necessity of providing diverse and whole foods. This approach has led to several single nutrient policies, such as food fortification, where the intake of a single nutrient is pushed, without any behavioural change in the population.

India’s policy on anaemia has focused on iron, and there is nothing immediately wrong with that. However, when this has failed, the answer lies in better implementation, or in innovative approaches that improve dietary iron absorption. Simply increasing the delivery of dietary iron also risks exceeding the limit of beneficial intake.

In contrast, perhaps the best example of a holistic approach is the lesson from the adoption of very stunted Indian children into Sweden. The height-for-age ratio of these children was improved by more than two standard deviation scores in the two years after their adoption. This was not the result of any single intervention, but from a general attention to health, a clean environment, diverse foods, and perhaps a great deal of love and attention.

In contrast, the rate of reduction in the prevalence of stunting is moving at the glacial annual pace of 1.3% in India, compared to much faster progress in neighbouring countries. Research encompassing multiple health factors, including affordability, availability and access to food, the ability to maintain healthy behaviours, and enabling circumstances, is important.

Another factor in India’s poor public health and nutrition, and sub-optimal research outputs, is the lack of sustained mentorship, capacity building and strengthening initiatives. The lack of a comprehensive understanding of this multidimensional problem, coupled with inadequate attention to nutrition education and research skills, undermines the country’s ability to reach the goals of the 2017-2020 National Nutrition Strategy.

There is great potential for finding solutions between sectors, including agriculture, economics, nutrition and health. Yet researchers across disciplines do not communicate effectively.

Research that has defined the nutritional demand or bioavailability of nutrients from different foods does not inform agricultural policy. Food production, procurement, distribution, and subsidy in India are still cereal-centric, when there is no good nutritional reason to remain this way. Recently, an online dashboard has been made available, which describes Indian food production, consumption, nutrient intake and health. It is hoped that research approaches that include the triangulation of national datasets and geospatial modelling will inform strategic research agendas and food policy. A network of researchers, policymakers and other stakeholders should formulate evidence-based policies, guided by India’s operational priorities. This is now happening with the establishment of the National Technical Board on Nutrition at the Niti Aayog, and bodes well for the nation.

Policymakers must use research to inform their decision-making. Funding support must be used to drive researchers to focus on providing solutions. Robust research that informs national schemes and programmes, along with effective advocacy and favourable economic policies, will help alleviate the country’s nutritional deficiencies.

[Shweta Khandelwal, Public Health Foundation of India, Delhi NCR, India. Giridhara R Babu, Intermediate Fellow, India Alliance; and Additional Professor, Public Health Foundation of India.Corresponding Author: Anura Kurpad, St John’s Medical College, Bengaluru, India. a.kurpad@sjri.res.in]

[Nature India Custom Edition: Decade of Discovery]