NUTRITION, HEALTH & NOURISHMENT: WHAT MATTERS AND WHAT NOT?

Dr. Antarjeeta Nayak
Founder Director, ARDF

INTRODUCTION

Malnourishment, often described as a silent epidemic, is a cruel paradox in a world where scientific advancements and agricultural innovations have made food more abundant than ever before.

TYPES OF MAL-NUTRITION: Malnutrition is a broad term that refers to deficiencies, excesses, or imbalances in a person’s intake of nutrients. It includes both undernutrition and overnutrition. The main types of malnutrition are:

1. Undernutrition Undernutrition occurs when the body doesn’t get enough nutrients or energy. This leads to various deficiencies and can be classified into four main types:

• Stunting (Chronic Undernutrition): This refers to low height for age. It occurs due to long-term insufficient nutrient intake and frequent infections, resulting in poor physical and cognitive development.
• Wasting (Acute Undernutrition): Wasting is low weight for height and is usually caused by severe and sudden malnutrition, often linked to illnesses or food shortages.
• Underweight: This occurs when a person’s weight is too low for their age, combining aspects of both stunting and wasting. It can indicate both chronic and acute malnutrition.
• Micronutrient Deficiency (Hidden Hunger): A lack of essential vitamins and minerals, such as iron, iodine, vitamin A, and zinc, leads to various health issues like weakened immunity, developmental delays, and increased mortality risks.

3. Protein-Energy Malnutrition (PEM)

PEM occurs when there is a severe deficiency of both proteins and calories. It is common in impoverished areas and comes in two main forms:

• Kwashiorkor: Caused by severe protein deficiency, it leads to edema (swelling), an enlarged liver, and a distended abdomen, with other symptoms such as hair changes and skin lesions.
• Marasmus: This is caused by a severe deficiency of both proteins and calories, resulting in extreme thinness, loss of muscle mass, and a "skin-and-bones" appearance. It is the most severe form of malnutrition.

4. Micronutrient-Related Malnutrition

This type includes deficiencies or excesses in specific vitamins or minerals:

• Iron Deficiency: Leads to anaemia, fatigue, and weakened immune function.
• Vitamin A Deficiency: Causes night blindness and increases the risk of infectious diseases.
• Iodine Deficiency: Results in goitre (swelling of the thyroid gland) and can lead to developmental issues in children, including cognitive impairment.
• Zinc Deficiency: Affects immune function, growth, and wound healing.
• Vitamin D Deficiency: Can cause rickets in children and osteocalcin in adults, leading to bone deformities and weakness.

5. Double Burden of Malnutrition

Some populations, particularly in developing countries, experience both undernutrition and overnutrition simultaneously. For example, stunted children may become overweight later in life, or communities may face high rates of obesity and micronutrient deficiencies at the same time.

In summary, malnutrition can manifest in various forms, from severe nutrient deficiencies to excess intake of unhealthy foods, each contributing to significant health challenges.

SYMPTOMS OF MALNUTRITION

Malnutrition, which includes both undernutrition and overnutrition, presents a range of symptoms depending on the type and severity of the nutrient deficiency or excess. Here are the key symptoms associated with malnutrition:

1. Symptoms of Undernutrition

Undernutrition results from insufficient intake of calories, proteins, and essential nutrients. The symptoms vary based on the severity and the specific nutrient lacking.

Stunted Growth: In children, chronic malnutrition leads to stunted growth, where the child's height is significantly lower than the average for their age.

Wasting (Severe Weight Loss): Extreme thinness, with muscle and fat loss, is common in acute malnutrition. The individual may look "skin-and-bones," indicating severe weight loss (wasting).

Underweight: Being underweight for one’s age is another general symptom of malnutrition, especially in children.

Anaemia: Iron deficiency, one of the most common forms of malnutrition, leads to symptoms like fatigue, pale skin, shortness of breath, dizziness, and a fast heartbeat.

Skin, Hair, and Nail Problems: Dry, flaky, or pale skin, hair loss, brittle or ridged nails, and the appearance of sores or lesions are common in nutrient deficiencies (e.g., vitamin C or zinc).

Cognitive Impairment: In children, malnutrition can lead to delayed cognitive development, difficulty concentrating, and poor academic performance. Adults may also experience memory issues and reduced cognitive function.

Swelling (Edema): In cases of protein deficiency, such as kwashiorkor, swelling of the feet, ankles, and abdomen may occur due to fluid retention.

Digestive Problems: Symptoms like diarrhoea, bloating, and constipation may arise due to nutrient deficiencies, affecting digestion and absorption.

2. Symptoms of Overnutrition

Overnutrition refers to excessive intake of calories or certain nutrients, often resulting in overweight and obesity.

Overweight and Obesity: Excess body fat, particularly around the waist, is a primary sign of overnutrition. It can also lead to difficulty in movement, shortness of breath, and fatigue.

Chronic Conditions: Overnutrition often leads to related health conditions like diabetes, high blood pressure (hypertension), and cardiovascular diseases.

Joint and Muscle Pain: Excess body weight can put strain on joints and muscles, causing discomfort or pain, particularly in the knees, hips, and lower back.

Shortness of Breath: Excess weight may lead to breathing difficulties, especially during physical activity or exertion.

Nutrient Imbalance: Even in cases of overeating, individuals may still suffer from micronutrient deficiencies (e.g., low vitamin D or calcium) if their diet is composed of calorie-dense but nutrient-poor foods.

3. Symptoms of Micronutrient Deficiencies

Micronutrient deficiencies (also called "hidden hunger") are often less visible but can lead to serious health problems.

Iron Deficiency (Anemia): Symptoms include fatigue, pale skin, dizziness, cold hands and feet, and frequent headaches.

Vitamin A Deficiency: Causes night blindness, dry eyes, and increased risk of infections.

Vitamin D Deficiency: Leads to bone pain, muscle weakness, and in severe cases, rickets in children (soft, weak bones) or osteomalacia in adults.

Iodine Deficiency: Causes thyroid problems, such as goiter (swelling of the thyroid gland), and developmental delays in children.

Zinc Deficiency: Causes slow wound healing, hair loss, poor immune function, and skin rashes.

The symptoms of malnutrition vary widely depending on whether it is due to undernutrition, overnutrition, or specific nutrient deficiencies. Recognizing these symptoms early is essential to prevent long-term damage to health and well-being, especially in children, pregnant women, and other vulnerable populations.

CAUSES OF MALNUTRITION

Malnutrition is a complex issue influenced by multiple factors, ranging from socio-economic and environmental challenges to healthcare access and dietary habits. Below is a more detailed exploration of the causes of malnutrition among children:

1. Poverty and Economic Insecurity

One of the leading causes of malnutrition in children is poverty. Families living in poverty often lack access to sufficient, safe, and nutritious food. They may rely on cheaper, low-nutrient foods to fill the stomachs of their children, leading to deficiencies in essential vitamins and minerals. Low household income also impacts access to clean water, sanitation, and healthcare, all of which are necessary for a child’s healthy development.

2. Inadequate Dietary Intake

Children require balanced diets to meet their energy and nutrient needs for proper growth and development. Inadequate intake of essential nutrients, such as protein, vitamins (like vitamin A and D), and minerals (like iron and zinc), can lead to both undernutrition and micronutrient deficiencies. Poor dietary diversity, which often results from economic constraints, exacerbates this problem, especially when diets are heavily reliant on starchy staples like rice, maize, or wheat, without enough fruits, vegetables, and protein sources.

3. Poor Maternal Health and Nutrition

A child’s nutritional status is often closely linked to maternal health and nutrition during pregnancy and breastfeeding. Malnourished mothers are more likely to give birth to low-birth-weight babies who are at higher risk of stunted growth, developmental delays, and chronic illnesses. Inadequate prenatal and postnatal care, as well as poor maternal education on infant feeding practices, can also contribute to malnutrition in infants and young children.

4. Infectious Diseases and Poor Health

Frequent infections like diarrhoea, pneumonia, and parasitic infections (such as intestinal worms) can significantly contribute to malnutrition. These diseases can impair a child’s ability to absorb and utilize nutrients, leading to a vicious cycle where malnutrition weakens the immune system, making the child more susceptible to further infections. In areas where access to clean water and sanitation is limited, infections can easily spread, worsening the nutritional status of children.

5. Lack of Access to Clean Water and Sanitation

Inadequate access to clean drinking water and proper sanitation facilities is a major contributor to malnutrition. Contaminated water sources and poor hygiene practices lead to waterborne diseases like diarrhoea, which deplete the body’s nutrients and energy stores, especially in young children. Without sufficient sanitation, children are also more prone to contracting infections that impair their ability to absorb nutrients.

6. Inadequate Breastfeeding Practices

Breastfeeding provides essential nutrients and antibodies that are crucial for a child’s growth, especially in the first six months of life. However, in many areas, cultural beliefs, lack of knowledge, or pressure to return to work may result in poor breastfeeding practices, such as early cessation or inadequate exclusivity of breastfeeding. The lack of appropriate breastfeeding contributes to malnutrition and weakens a child’s immune system, making them vulnerable to infections.

7. Early Introduction of Inappropriate Complementary Foods

After six months, infants need solid foods alongside breast milk to meet their increasing nutritional needs. However, in many low-income and rural areas, complementary foods are often introduced too early or too late and may be of poor nutritional quality. Foods provided may lack protein, fats, or essential micronutrients, leading to inadequate calorie and nutrient intake.

8. Food Insecurity Due to Environmental Factors

Natural disasters like droughts, floods, and food shortages can lead to spikes in malnutrition among children. Climate change further exacerbates these challenges, disrupting agricultural production and food supply chains. Families affected by these events may find themselves unable to provide regular and nutritious meals for their children, causing hunger and nutritional deficiencies.

9. Social and Gender Inequality

In many societies, social and gender norms affect how food and healthcare resources are distributed within a household. In some cultures, women and children, particularly girls, may eat last or receive smaller portions, limiting their access to essential nutrients. Additionally, girls in particular may suffer from malnutrition due to early marriages and pregnancies, which put extra strain on their developing bodies.

10. Limited Access to Healthcare Services

In many regions, especially rural or conflict-affected areas, healthcare services are either inadequate or inaccessible. Children in these areas may not receive proper medical care or timely interventions for malnutrition-related conditions. Immunization coverage is often low, and routine growth monitoring, which could help identify malnutrition early, may be lacking. This limited access also includes a lack of vitamin supplementation programs, deworming, and treatment for common childhood illnesses.

11. Cultural Beliefs and Practices

Cultural beliefs and misconceptions about food and child-rearing practices can contribute to malnutrition. For instance, certain foods may be considered taboo for children or pregnant women in some cultures, leading to an unbalanced diet. Traditional feeding practices, such as withholding food during illness or not giving nutrient-rich animal products, may also lead to nutrient deficiencies.

12. Lack of Education and Awareness

Parental education, particularly maternal education, plays a critical role in preventing malnutrition. When parents lack knowledge about proper child nutrition, including the importance of breastfeeding, balanced diets, and hygiene, children are more likely to suffer from malnutrition. Educating communities about the importance of nutrition, sanitation, and disease prevention can make a significant difference in improving children’s health outcomes.

Addressing malnutrition requires an integrated approach, focusing on improving food security, healthcare services, maternal and child education, and access to clean water and sanitation. Coordinated efforts from governments, non-governmental organizations, and communities are essential to break the cycle of malnutrition and ensure a healthier future for children worldwide.

‘MAL-NOURISHMENT’: THE PERSISTENT PLAGUE

Mal-nourishment speaks of a condition where food, the most basic of human rights, is often a luxury, where each meal is a gamble. With 60% of the India’s population living on less than $3.10 a day, and 21% on less than $2, India has the highest number of undernourished people globally, where 14.37% of the population lacks adequate nutrition and mal-nourishment is a haunting reality that continues to plague millions. According to Global Hunger Index 2023, India's 2023 GHI score is 28.7, indicating serious hunger issues with dire consequences of high mortality, stunted growth, weakened immune systems, cognitive impairments, and a vicious cycle of poverty. Despite significant strides in economic growth, the country still grapples with a high burden of malnutrition. According to the National Family Health Survey-5, 2019-21, 35.5% of Indian children under the age of five are stunted, 19.3% are wasted and 32.1% are underweight. Children who are malnourished in their early years are more likely to suffer from impaired cognitive development, lower educational attainment, and reduced earning potential as adults. The World Bank estimates that malnutrition can lead to a loss of 10% of an individual's lifetime earnings, contributing to the vicious cycle of poverty that entraps entire generations. A study by the International Food Policy Research Institute, suggests that India loses 4-5% of its Gross Domestic Product annually due to malnutrition-related productivity losses and healthcare costs, hampering India’s aspirations to become a global economic powerhouse. Malnourished children are more likely to drop out of school, limiting their future opportunities and trapping them in a cycle of poverty and anti-social activities, thereby creating a social burden. Families with malnourished children often face significant emotional and financial stress, leading to a range of negative outcomes, including poor mental health for caregivers and decrease in overall family well-being.

‘MALL-NOURISHMENT’: THE EPIDEMIC OF EXCESS

On the flip side of this nutritional dichotomy lies ‘mall-nourishment’—that aptly describes urbanization and the rise of consumer culture where people are too busy to cook, and rely on the convenience of packaged foods, where behind the cheerful demeanour lies a growing health concern—'mall-nourishment’.

ADDRESSING THE CRISIS

The World Inequality Report 2022 highlights India as one of the most unequal countries, with the top 10% and 1% holding 57% and 22% of the national income respectively, while the bottom 50% share has dwindled to just 13%. This growing income inequality creates a stark divide, creating a tale of two India— “mall-nourished India” and “mal-nourished India”, threatening economic growth and deepening social inequality, that needs intervention. Some possible action plans include-

• Nutritional Status Assessment- Comprehensive baseline survey can assess the nutritional status of children using anthropometric measures (weight-for-age, height-for-age, weight-for-height).
• Targeted Nutritional Supplementation-Providing age-appropriate nutritional supplements focusing on high-protein, micronutrient-rich foods.
• Promotion of Local Nutrient-Rich Foods- Encouraging the cultivation and consumption of local, seasonal, and nutrient-rich foods such as millets, fresh green leafy vegetables, fruits, and pulses over packaged, preservative-laden options can greatly reduce the prevalence of anaemia and improve overall health. Supporting local agriculture through farmers' markets and community-supported agriculture programs, along with incorporating these foods into school meals and public health campaigns, can encourage healthier eating habits and decrease reliance on processed foods.
• Strengthening the Public Distribution System (PDS)- Ensuring that the PDS supplies fortified foods, particularly rice, with essential micronutrients. Food fortification with multiple micronutrients may reduce anaemia by 32%, micronutrient deficiencies, including iron deficiency by 56%, vitamin-A deficiency by 58%, vitamin-B2 deficiency by 64%, vitamin-B6 deficiency by 91% and vitamin-B12 deficiency by 58%.
• Promote Dietary Diversity- School kitchen gardens and community agriculture can improve access to diverse food groups, boosting dietary diversity and micronutrient intake. A balanced diet with five food groups can reduce stunting by 21% and micronutrient deficiencies by 25%.
• Community-Based Nutrition Programs- Public health campaigns like ‘Fit India Movement’, ‘Eat Right India’, ‘POSHAN MAAH’ that emphasize the importance of balanced diets, regular physical activity, and the dangers of excessive consumption of unhealthy foods, through regular community health and nutrition education sessions are crucial. Active community engagement can lead to a 10-15% reduction in mal/mall nutrition rates.
• School-Based Nutrition Programs- Nutritional education should be part of school curricula to instil healthy eating habits early on. Schools should also offer nutritious meals and promote physical activity to combat obesity and sedentary lifestyles related conditions.
• Monitoring and Evaluation- Implementing robust digital monitoring tools and an evaluation framework can boost nutrition program success by 30% by identifying gaps and enhancing program implementation through data-driven adjustments.
• Awareness programs for parents- To make informed choices about the foods they provide for their children, ensuring that convenience does not come at the cost of nutrition.

CONCLUSION

Malnutrition casts a long and ominous shadow over India's economic prospects, serving as both a cause and consequence of the country’s deep-rooted social inequalities. According to recent studies, malnutrition is responsible for nearly 68% of child deaths in India, and the country is home to one-third of the world’s stunted children. This widespread nutritional deficiency not only hampers individual health but also severely constrains economic development, perpetuating cycles of poverty across generations. To build a prosperous and resilient future, India must prioritize the nutrition and well-being of its citizens, starting from infancy. Evidence from organizations like UNICEF and the World Health Organization has consistently shown that proper nutrition in the early years of life can significantly improve cognitive function, educational outcomes, and productivity in adulthood. Malnutrition, particularly in the form of stunting, wasting, and micronutrient deficiencies, leads to irreversible physical and cognitive impairments, resulting in diminished economic output and increasing healthcare costs. In India, it is estimated that malnutrition may reduce GDP by up to 3%, primarily due to the loss of productivity and the burden of treating nutrition-related illnesses. Addressing malnutrition also plays a critical role in reducing social inequality. Marginalized communities, particularly those in rural and tribal areas, bear the brunt of food insecurity and inadequate access to nutritious foods. Women, who are often the primary caregivers, face the added challenge of ensuring proper nourishment for their children despite limited resources. Malnutrition disproportionately affects girls and women, further entrenching gender inequality as undernourished girls grow into undernourished mothers, perpetuating a cycle of poor health across generations. By investing in comprehensive nutrition programs—such as improving access to fortified foods, promoting breastfeeding, encouraging local agricultural practices, and increasing nutritional literacy—India can unlock the full potential of its future workforce. Improved nutrition will not only boost individual health outcomes but also enhance labor productivity, stimulate educational achievements, and reduce the economic burden of healthcare. The country must also focus on maternal nutrition and early childhood interventions, which have been proven to yield a high return on investment in terms of health, economic development, and social cohesion. In paving the way for a nourished, healthy population, India can effectively break the chains of malnutrition that limit its economic and social progress. By nurturing the health of its citizens today, the nation stands poised to harness the strength of its human capital, reduce inequality, and cultivate a more just and equitable society.

-Abhibyakti Research and Development Foundation (ARDF)