“The twin burden of undernutrition and overnutrition coexist in this country,” says Dr Ishi Khosla, clinical nutritionist and founder of Whole Foods India.

The crisis of child malnutrition is growing in India, where the majority of children under the age of five are undernourished. The last National Family Health Survey found in 2020 that acute undernourishment and stunting had gone up in most of the states and union territories for which data has been released.

The same year the Indian government refused to extend midday meals to include breakfast, citing a shortage of funds.

“Children are stunted, and 24% of adolescents are thin for their age,” Khosla explains. She adds that poor nutrition also affects “the mental health and the intelligence quotient of these children.”

At the other end of the spectrum of bad nutrition are “metabolic diseases and lifestyle related diseases,” which were earlier thought of as an urban problem, “but now we are finding that they are also affecting the rural population,” says Khosla.

This year’s Global Hunger Index confirms the gnawing problem - and the Indian government promptly dismissed its findings as an opinion poll. India ranks 101st of 116 countries in the index, its score of 27.5 indicating a “serious” level of hunger, on a par with Afghanistan and Somalia, and well behind Pakistan, Bangladesh and Nepal.

The GHI score is calculated using the extent of total undernourishment in a population, and for many countries it relies on government data - on child stunting (low height for age), child wasting (low weight for height) and child mortality.

With tens of crores of Indians thought to have been pushed back into poverty since the mismanaged pandemic and lockdowns, people’s ability to buy nutritious food has also been affected, making a chronic problem worse. At the other end of the spectrum, overnourished adult men and women outnumbered the undernourished for the first time in 2016, and the gap has since increased.

“I think it is a grave situation.. Issues like intrauterine growth restriction, low birth rate, infant mortality, anaemia, iron deficiencies, iodine deficiencies, wasting, stunting - and on the other side metabolic diseases - everything is worsening,” Khosla tells The Citizen.

On gendered malnutrition, she adds, “There has been no progress in anaemia. And even though the communications around breastfeeding have improved, still has it led to any improvement in overall health stats?”

According to Khosla a leading factor in this national problem is malabsorption, a condition that prevents the small intestine from absorbing nutrients.

“It’s not the affordability or distribution anymore. We have everything in surplus… The root problem is in the gut. If the gut is not addressed, if the absorption is not addressed, we will not make a difference,” she says.

Vijeta Ananth Kumar, currently working at the Centre for Monitoring Indian Economy, also brings up malabsorption as one of the prenatal factors affecting child nourishment.

“Every second expecting mother is anaemic” in India, she explains, “which has a huge impact on the children they bear in that family, because they are automatically born anaemic. You really have to go one step ahead in helping them absorb the nutrition, because they are already weaker in that regard.”

Kumar has been a key volunteer at Adamya Chetna, an organisation run by her mother Tejaswini Ananth Kumar that provides midday meals to over 800 schools in Karnataka and Rajasthan.

After over 10 years of working in the field, Kumar thinks the best way to provide consistent and nutritious mid day meals to kids is by centralising the process.

“It becomes very tough for schools or local kitchens to prepare themselves, because the smaller the quantities you make, the more expensive it is. Only when you scale it up does it become slightly cheaper. So centralised kitchens would be a better solution in this case,” she tells The Citizen.

Centralisation also helps overcome the problems chronic to states that lag in health provision, like Jharkhand and Bihar. “I have personally been to these states and done some amount of fieldwork there,” says Kumar. “They are unable to keep up.. I think a centralised system works best for this scheme.”

She explains that nutritional deficits lead to problems in academic performance. After Adamya Chetna started work in teacher training in public schools, “we realised that the real issue in government schools in India is that often students are not getting a nutritious meal, because of which their attention spans are really low.”

Those attending public schools are often girls and the lowered castes - the children of labourers and daily wage workers.

“They live in slums,” says Kumar, where “they have very little access to clean drinking water or nutritious meals. We also realised that most students would come without having had dinner the previous night, and with very little or very bad breakfast before coming to school. Even one full meal with dal and vegetables was difficult for these students.”

She brings up the price hike in dal in 2014-15, when it became even more difficult for oppressed-class parents to provide full meals with pulses and green leafy vegetables for their children. Their kitchens were also affected by this hike, as efforts to ensure food entitlements don’t go nearly far enough.

While the government provides a set amount of rice and dal, along with a cash allowance of about 10 rupees per person for oil, vegetables, spices, etc, with the allowance varying from region to region, “This is very insufficient for students, because of course you can’t just do with rice and dal.”

Typically, the actual expenses go beyond what the government provides.

“Of course we have a long long way to go,” says Kumar. “We really have to incorporate superfoods, like nuts and local seeds - this is something that we need to think of providing as a society, because some of these things can be made affordable.”

She also cites the example of locally grown millets, which are typically very cheap but are hardly ever incorporated in government plans for midday meals.

“Midday meals have played a very big role, because you can clearly see a drastic improvement in attendance levels.. Often this is the only complete meal that they are getting. If you speak to the students and teachers, they clearly look forward to coming to school for the meal.”

Kumar points out that when children’s stomachs are full, they are also more enthusiastic to learn, and are able to grasp much more - so of course they enjoy learning after a hot and filling meal. “They are able to play, take part in physical activities and even learning improves.”

Child and maternal malnutrition is estimated to be responsible for 15% of Indians’ total disease burden, according to a report based on NFHS data.

While child malnutrition is often blamed on low incomes, it is clear from international comparisons that many countries with graver poverty are faring better than India when it comes to hunger.

And as the economists Jean Drèze and Amartya Sen have highlighted, India has fallen behind its neighbouring countries on several indicators of nutrition and health, while overtaking them on measures of income per capita, due to the absence of state intervention in public health.

Kumar thinks there are certain government policies that are going in the right direction, and need to be taken further. She says the addition of milk three times a week to the midday meals in Karnataka was a very good move, and resulted in “a huge push to the nutrition levels. When we did a rough survey we found that it’s almost never that these children get to drink milk.”

While most states have struggled with providing milk for midday meals, some have also been confronted with a religious dilemma - whether to include eggs in their midday meals.

Kumar thinks it is not only a question of vegetarianism by diktat. “Eggs is a very tricky thing - first of all it is very difficult to get so many eggs of good quality, and then to check if it is ‘off’, and then to manage thousands of eggs is very difficult I think. People talk about eggs, or no eggs, and make it a vegetarian issue, but I think the bigger issue is the fact of maintaining quality.”

A 2019 survey found that governments were providing eggs in midday meals in 13 states, ranging from one egg per week in erstwhile Jammu and Kashmir, Bihar, Kerala and Assam to five eggs per week in Andhra and Tamilnad.

So long as the children are getting all their food groups and the required nutrition, including protein, it should not be politicised, says Kumar.

“We can address this issue,” she emphasises. “In all my field studies, I have not been to any place where there is no access to food. There is no lack of vegetables or food grains. We are unable to process that and provide it to our children.”

What we need is “a system that is actually functioning, that needs some level of administration. I don’t think lack of resources is the problem at all.”