Cultural Change Is Essential

BMJ 2011; 343 doi: 10.1136/bmj.d7242 (Published 11 November 2011) Cite this as: BMJ 2011;343:d7242


by Veena Rao, adviser, Karnataka Nutrition Mission

Source :

The contradiction between India’s reduced poverty plus high economic growth and the continuing high prevalence of childhood undernutrition is not as surprising as it might seem. Economic growth, mostly fuelled by the non-agricultural sector, has not reduced unemployment1; nor has it benefited the undernourished poor. Agricultural growth as a percentage of gross domestic product, per capita availability of food grains, and per capita consumption of food grains is declining.2 Double digit food inflation is further reducing nutritional intake by people who are already undernourished. Furthermore, additional income in poor households does not necessarily result in better nutrition; households may opt to spend money on consumer items, such as mobile phones and television sets.


Although undernutrition in children is, as Haddad underlines, India’s most glaring nutritional problem, female undernutrition, to which childhood undernutrition is inextricably linked, is equally worrying. Adolescent girls in India are the most undernourished in the world,3 and a third of adult women have low body mass index.4 Average weight gain during pregnancy is only 5 kg,5 and 28% of all infants have a low birth weight.3


The causes of India’s undernutrition problems include historical, economic, epidemiological, behavioural, and governance factors. They are rooted in:


• Protein, energy, and micronutrient deficiency, affecting 30% of the population 67

• The intergenerational cycle that links undernourished adolescent girls, pregnant women, and low birthweight babies (figure)

• Lack of awareness about proper nutritional norms and child and maternal care

• Sex inequity throughout life, translating into lower nutritional intake for female family members, and a cultural tradition that does not promote dietary supplementation during pregnancy

• Low political priority and absence of an integrated national programme with the explicit objective of reducing undernutrition.




Two concentric cycles affecting nutrition: the intergenerational cycle of undernutrition and the cycle of energy deficit and poverty


India’s undernutrition problems can therefore be tackled successfully only through an integrated programme that addresses all these factors and is coupled with explicit and monitorable targets. The first priority should be the population with protein-energy deficit. Existing food supplement programmes have poor coverage; they are more subsistence programmes than food security programmes. India should also launch a public nutrition awareness programme to stimulate behavioural change and demand from undernourished households. Negative cultural practices and superstition regarding proper nutrition and care of children and women, prevalent among the population, especially rural households, need to be removed.


Haddad’s call for a national strategy to combat undernutrition in India provides welcome academic support to those of us who have been advocating this for the past decade. National commitment is needed to back state level action, which in Karnataka has already prompted the development of a comprehensive nutrition mission strategy that is being piloted.