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Nutrition In The News: Sharp Diagnoses And Converging Policy Instruments

“Sharpness in the diagnosis is important, as is sharpness in bringing together policy instruments that address those determinants. I believe this is now doable in India because the data is available to do this district by district.”

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This interview is part of BW Sustainability’s series Nutrition in the News. BWs Neeta Misra speaks with Purnima Menon a senior Research fellow at the International Food Policy Research Institute (IFPRI)

Persistent malnutrition is a phrase commonly used for India, why is that? 

People have referred to malnutrition in India as being persistent because of the perceived slow pace of change.  While that slower than desired pace is true for the national average, it’s not quite true for the states within India, which are progressing at very different rates.  There are success stories in stunting, for example, with states such as Chhattisgarh leading the pack with high rates of decline.  At the same time, we also see the emergence of new forms of malnutrition (overweight, obesity) in many parts of India, and little change in other forms of malnutrition. 

So, in fact, our sense is that malnutrition – in all its forms - is persistent but there is variability in how it manifests across India and in how it changes.  And for us as researchers, there is a lot to be learned from understanding what is in fact an evolving mix of multiple forms of malnutrition. 

How does gender impact on nutrition? 

Gender continues to underpin the high burden of some forms of malnutrition that we see in India – stunting, wasting and anemia in particular.   And when I say gender here, I don’t really mean boy-girl differences in these outcomes.  For me, the ways in which girls and women are invested in and treated lies at the heart of how we should think about gender and malnutrition.  Our research shows, over and over again, that factors related to these investments are among the most salient determinants of malnutrition.  Our work on stunting in India, for instance, shows that maternal educational levels, maternal age at marriage, maternal nutrition and access to antenatal care, together account for close to half of the difference in stunting between high- and low-stunting districts.  That’s a HUGE contribution of gender-related factors – each of those indicators is a marker for how girls and women are invested in, valued and treated throughout the life course from childhood to adulthood! 

When we think about nutrition what are some of the other interlinked issues for combating malnutrition? 

Oh, poverty, without a doubt – and the many other things that are the ramifications of poverty (sanitation, access to health care, diets, etc.).  We don’t talk enough about this but the fact is that poverty matters so much, both for undernutrition and also around healthy diets.  Our research shows that household wealth distinguishes between high and low stunting districts, for instance, and in other work, we’ve shown that improvements in household wealth contribute substantially to declines in stunting over time as well.  So, we have to acknowledge this, and identify the best ways to address something that is such a drain on families.  Poverty affects people’s choices in every way possible – choices of where they live, what access they have to sanitation, what choices they have for health care, of what foods they can eat.  What does this mean for policy?  Primarily, it means that the nutrition community needs to align strongly with the policy communities around social protection to find ways to work together to address both the income constraints to eating health foods and the information constraints (e.g., improving people’s awareness of how to use resources to make healthy food choices).  Our studies on cash transfers and nutrition behaviour change in other countries highlights these intersections very clearly.  

What do we mean by a 'healthy diet'? 

A healthy diet – it’s hard to define a single type of healthy diet (although the just released work by the EAT-Lancet Commission tries to do so).   As a nutritionist and a parent, I think of a healthy diet as a diverse diet – diversity, freshness and colour on our plates is the simplest way to think of healthy diets.   And real food, not ultra-processed products.  And not too much of anything (other than vegetables!).  While this is easy to say, it’s awfully hard to put into practice, especially for busy parents.  And it’s even harder for the poor who are also busy trying to make a livelihood and hold so many things together for themselves and their families.  Around health diets, I also worry a lot about helping people make healthy choices, even those with ample resources at their disposal. I’m mostly appalled by the food choices that are often available around us (in markets, airports, restaurants, malls) and am worried when I see people making unhealthy food choices routinely and frequently.  So, I also do worry, increasingly so, about the emerging burden of overweight, obesity and diet-related non-communicable diseases in India.  A huge shock in the National Family Health Survey data we’ve been working with has been the fact that 1 in 5 Indian women and 1 in 7 Indian men are now overweight!  

If you had to prioritise one policy measure right now what would that be? 

As someone who’s been studying this issue for two decades now, I am afraid I have to say - with a lot of conviction - that malnutrition cannot be solved by one policy measure!  Both because there are many forms of malnutrition and because there are key underlying determinants that cannot be solved by one policy measure.  That said, India is in a good spot right now with existing policy instruments that have the potential to address the many determinants of poor nutrition outcomes so it’s less about finding the one policy measure and more about figuring how to mobilize and deliver on those instruments that do exist.  In this context, I ask myself what can policymakers and other interested parties (e.g., philanthropies) do?  

In my view, it’s time for reducing distractions and sharply prioritize instruments that address context-specific determinants of malnutrition.  For instance, in some districts in India, it’s likely that childhood stunting is primarily because of high rates of early marriage and early pregnancies.  In those areas, by identifying the reasons why girls are not in school can you start to address early marriage and early childbearing.   In other areas, anemia may be a bigger challenge than other forms of malnutrition and could be because of poor diets or high rates of infection; and certainly, India has policy instruments then to address those challenges!  

Sharpness in the diagnosis is important, as is sharpness in bringing together policy instruments that address those determinants.  I believe this is now doable in India because the data is available to do this district by district.   Given that the policy instruments are available, driving accountability could be one of the most important policy measures…with some caveats.  My primary caveat is that holding people (e.g., district officials or state officials) accountable for outcomes such as stunting that are quite downstream of the policy instruments they possess to address those can be challenging.  I believe that accountability should be at the level of performance outcomes that implementers, administrators and policymakers have the power and responsibility to change in the time frames that they serve in their positions.  This means a very sharp accountability focus on policy outcomes such as reach of services, enrollment of girls in school, on the enactment of the laws against early marriage, on provision of maternal and child health services, on implementation of policy instruments such as the PDS, NREGS, and other programs and schemes.  These actions, together, have the potential to address almost ALL the determinants of stunting among children, of anemia and accountability for actions must be a priority. 

Lastly, I think policy measures that look at improving access to healthy diets for ALL – not just the poor – are really important.  The poor often emulate the middle-class and the rich, so working with people across the economic continuum to enable healthy food choices is essential.  

Tell us about IFPRI's work in nutrition? 

Purnima:  IFPRI’s work on nutrition in India is wide-ranging.  We do both research and communications (of our research).  I’d characterize our research around three areas, if I had to summarize – (1) characterizing and describing the challenge of malnutrition (who’s affected, by what, where, and how many); (2) understanding the drivers of malnutrition in all its forms (what factors affect what forms of malnutrition; what factors seem to be contributing to changes over time and differences across states and districts); and finally (3) identifying solutions (what is the reach of existing solutions, e.g., of the various programs – the Integrated Child Development services (ICDS), health programs, Public Distribution System (PDS), school meal programs, etc.and also on testing solutions! We do a lot of program evaluation research testing solutions – e.g., we have been fortunate to study the roll-out of the technology component of the national nutrition mission in two states; we are doing research to test behaviour change communications strategies and are doing research on how women’s self-help groups can contribute to improving nutrition. We are deeply interested, as policy-focused researchers, in testing implementation solutions that can improve India’s existing policy instruments.  

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