The double burden of malnutrition in India

P. Ramachandran, Director, Nutrition Foundation of India, New Delhi

Introduction

India is a vast and varied subcontinent. Covering 2.4 percent of the global landmass, it supports more than one-sixth of the world’s population. In 200 1, India’s population had reached 1 028 million people, living in 220 million households in 35 states and union territories (Map). As a developing country with high population density, ever since Indian independence, planners in India have recognized the importance of planned growth of the economy emphasis on human resource development. Policy-makers recognize that optimal nutrition and health are prerequisites for human development. Article 47 of the Constitution of India states that "the State shall regard raising the level of nutrition and standard of living of its people and improvement in public health among its primary duties". Over the last five decades, successive five-year plans have lain down policies and multisectoral strategies to combat nutrition-related public health problems and improve the nutritional and health status of the population.

Currently, the country is undergoing a rapid socio-economic, demographic, nutritional and health transition. Although India has not yet overcome the problems of poverty, undernutrition and communicable diseases, it is increasingly facing additional challenges related to the affluence that results from industrialization, urbanization and economic betterment. Over the last two decades, overnutrition and obesity have emerged as public health problems; there have been increases in the prevalence of diabetes and cardiovascular disease (CVD), especially in urban areas. The magnitude of these problems varies among states and socio-economic strata and between urban and rural areas, and it is a matter of concern that these diseases occur a decade earlier in India than elsewhere and that they affect poor segments of the population and those in rural areas. Case fatality rates are reported to be higher in poor and rural populations, probably because of poor access to health care and consequent delayed diagnosis and treatment. This case study reviews the impact of ongoing socio-economic, demographic and life style transitions on nutritional status, and the health implications of the ongoing nutrition transition.

Demographic transition

Demographic transition is a global phenomenon. Technological advances and improved quality and coverage of health care have resulted in a rapid fall in India’s crude death rate, from 25.1 per 10 000 population in 1951 to 9.8 in 1991. The reduction in crude birth rate has been less steep, falling from 40.8 per thousand in 1951 to 29.5 in 1991 (RGI, 1951 to 2001). As a result, the annual exponential population growth rate was more than 2 percent from 1971 to 1991. The census of 2001 confirmed that the pace of demographic transition in India has been steady, albeit slow, and that India has joined China in having a population of more than 1 billion (Figure 1).

FIGURE 1
Population and birth and death rates in India, 1951 to 2001

Source: RGI, 1951 to 2001.

Box 1. Population projections 1996 to 2016

Source: RGI, 1996.

Population projections for the period 1996 to 2016, carried out by the Registrar General of India (RGI, 1996) are given in Box 1. Although there has been a substantial reduction in birth rates, population growth will continue for the next three decades because of:

• the large proportion of the population in the reproductive age group (contributing about 60 percent of total population growth);
• high fertility caused by a lack of contraception (contributing about 20 percent of total population growth);

• high desired fertility resulting from the prevailing high infant mortality rate (contributing about 20 percent of total population growth).

FIGURE 2
Population projections for India, 1996 to 2016

Most of India’s population growth between 1996 and 2016 will be caused by increased numbers of people in the 15 to 59 years age group - the working age (Figure 2). The Malthusian assumption that population growth leads to overcrowding, poverty, undernutrition, environmental deterioration, poor quality of life and increase in disease burden has been challenged in the last few decades; population growth can also be a major resource for economic growth, as outlined in Box 2. If India successfully faces the challenge of providing its younger, better-educated, skilled, well-nourished and healthy workforce with appropriate employment and adequate remuneration, the economic status of both the people and the country can improve rapidly.

Box 2. Economic implications of demographic transition

The current phase of demographic transition also represents a major opportunity for improving the health and nutritional status of the population. The under 15 years age group will not increase in numbers. The health and nutrition infrastructure will therefore not have to cope with ever-increasing numbers of children needing health and nutrition care, leaving it free to concentrate on the quality and coverage of health and nutrition services needed to improve health and nutritional status. If the health and nutrition needs of the literate and aware 15 to 59 years age group are met, massive improvement in nutrition and health status can be made. Appropriate counselling will enable people to adopt life styles and diets that prevent the escalation of overnutrition and the attendant non-communicable disease (NCD) risk. For the increasing numbers of people over 60 years of age, provisions for managing their nutritional and health problems would have to be made.

Economic transition

Since the 1950s, India has adopted the concept of a mixed economy for overall agricultural and industrial development. In the last decade, the service sector has become the high-growth sector. Over the last three decades, there has been a steady increase in gross domestic product (GDP) and per capita net national income; per capita net national product reached US$237 in 2000 (Government of India, 2003). Agriculture remains a major determinant of GDP growth, and is the most important sector for rural employment. Over the years there has been slow but steady reduction in poverty (Table 1), which had declined to 26.2 percent in 2000 (Planning Commission, 2004). Rises in per capita income (Figure 3) have not been matched by increased energy consumption (NNMB, 1979 to 2002), and there are large inter-state differences in per capita income and poverty ratios.

FIGURE 3
Trends in per capita income and energy intake, 1974 to 2002

TABLE 1
Economic indicators, 1950 to 2001

US$1 = RS 43.5.
Sources: Government of India, 2003; * Planning Commission, 2003.

Social transition

Improvement in the quality of life is the central pillar of India’s planned development. The adult literacy rate improved from 18.3 percent in 1951 to 65.4 percent in 2001 (Table 2). India now has the world’s largest trained workforce in science, administration and technology. Attempts are under way to ensure universal primary education and to improve secondary and vocational education (Government of India, 2003). Efforts are also being made to ensure that higher and technical education gets due attention (Table 3) (Department of Education, 2002). The urban population has continued to grow because of rural-urban migration; in 2001, 30 percent of Indians lived in urban areas. Of the 26 megacities (each housing more than 10 million people) that are forecast worldwide by 2015, five will be in India.

Although urban amenities have failed to cope with the increase in population, cities and towns have become the engines of social change, rapid economic development and improved access to education, employment and health care. Rural and urban populations continue to lack access to safe drinking-water (38 percent in 1981 and 68 percent in 2001) and good environmental sanitation (less than 30 percent) (RGI, 1951 to 2001). With better communication and transportation, urban and rural areas can be linked, both economically and socially, to create an urban-rural continuum of communities and to achieve sustained, rapid improvement in quality of life in both.

TABLE 2
Social indicators, 1950 to 2001

Source: Government of India, 2003.

TABLE 3
School enrolment by gender (millions), 1970 to 2001

Source: Department of Education, 2002.

Health transition

Over the last five decades, there have been steady but slow reductions in the rates of births, deaths, infant mortality and under-five mortality (RGI, 1971 to 2000) (Table 4). India still has high infant, perinatal and neonatal mortality (Figure 4), but there has been a steady reduction in the death rate and an improvement in longevity.

FIGURE 4
Child mortality indicators, 1971 to 1997

Source: RGI, 2000.

TABLE 4
Health indicators, 1950 to 2001

Source: Government of India, 2003; RGI, 2000; UNDP, 2003.

Access to health services is still sub-optimal, especially in remote areas with high morbidity. Immunization coverage is low (complete immunization coverage at 12 months was 35.4 percent in 1992/1993 and 42.0 in 1998/1999), and child morbidity and mortality rates are high (IIPS, 1992/1993; 1998/1999). India’s shares of global communicable disease and maternal and perinatal problems are high and have not shown substantial reduction in the last two decades (Box 3) (Planning Commission, 2002). The estimated disease burden to communicable diseases and ischaemic heart disease (IHD) is shown in Table 5. Diabetes and CVD have shown sharp rises in the last two decades; India faces the dual burden of high communicable and rising non-communicable disease prevalence (World Bank, 1993).

Box 3. India’s share of global health problems

Source: Planning Commission, 2002.

TABLE 5
Burden of five major diseases (million DALYs)1

¹ DALY = disability-adjusted life year.
- = less than 0.05 million.
Source: World Bank, 1993.

Sustainable food production to meet nutritional needs

Nutritionists view agriculture as an input for dietary intake, while farmers look for returns on their investments. The green revolution showed that food grain production can be increased fourfold when farmers are assured of returns on investment (Figure 5). However pulse and coarse grain production has stagnated (Ministry of Agriculture, 2002a).

Cereals and pulses

Over the last five decades, the per capita net availability of cereals has been improving, and by 1991 it was sufficient to meet the recommended dietary allowance (RDA) (Figure 6). However, per capita pulse availability and consumption have declined. Pulses are a major source of protein among poorer segments of the population, so this trend must be reversed (Ministry of Agriculture, 2002b).

FIGURE 5
Trends in production of important food items, 1950 to 2001

Source: Ministry of Agriculture, 2002a.

FIGURE 6
Per capita net availability (per day), 1950 to 2001

Source: Ministry of Agriculture, 2002b.

Horticulture

Vast areas of India are subtropical, and agroclimatic conditions are well suited to the cultivation of vegetables, fruits and plantation crops. Horticultural products provide higher yields per hectare, obtain higher sale prices and sustain agro-industries. As a result, greater areas are being brought under horticulture, and the production of fruits and vegetables is increasing. In 2000, India produced 46.6 million tonnes of fruits and 96.5 million tonnes of vegetables. Less than 1 percent of this production is processed. Losses during packaging and transport are about 30 percent.

Except among affluent urban segments of the population, per capita vegetable and fruit consumption continues to be low because of problems with access and affordability. Investment in infrastructure for preservation, cold storage, refrigerated transportation, rapid transit, grading, processing, packaging and quality control will help the horticultural sector to achieve its full economic potential and to provide vegetables and fruits at affordable cost throughout the year. In this way, the micronutrient needs of the population can be met through a sustainable food-based approach.

National agricultural policy

The National Agricultural Policy (NAP) (Ministry of Agriculture, 2000) emphasizes crop diversification, horticulture and food processing for sustainable agriculture growth. NAP and the Tenth Five-Year Plan (Planning Commission, 2002) have set a target of a 3.97 percent growth for agriculture. This is to be achieved through:

• efficient use of resources and the conservation of soil, water and biodiversity;

• equity across different regions and farmers;

• a demand-driven approach that caters to domestic markets and maximizes the benefits of exporting agricultural products in the face of the challenges of economic liberalization and globalization;

• technological, environmental and economic sustainability.

Increasing economic growth and improved access are expected to lead to dietary diversification and increased consumption of pulses, vegetables, fruits and dairy products. Once dietary diversification at affordable cost is possible and the majority of the population have a balanced diet, it will be possible to achieve nutrition security.

MAP: INDIA'S STATES (CENSUS INDIA)