Stunting currently affects 35.5% of children in India. Affected children being too short for their age, also suffer irreversible physical and mental damage. A stunted child is likely to perform poorly in school, experience chronic health problems and has lower earning potential as an adult. In essence, the fate of a child is sealed by the care they receive in the first 1000 days of their life. If such care is insufficient, stunting peaks between 18-23 months of age and becomes irreversible after the first 1000 days.
Decoding the health condition
Stunting in individuals constitutes a ripple effect, potentially incapacitating a nation’s human capital and progress. As per the World Bank, one per cent of shortening in adult height due to childhood stunting is associated with a 1.4 % loss in economic productivity. In India, as per the National Family Health Survey-4, the states of Bihar (48%), Uttar Pradesh (46%), and Jharkhand (45%) have witnessed the highest levels of stunting prevalence. In comparison, Kerala and Goa have the lowest rates at 20%, with 40% of the country’s districts having stunting levels above 40 per cent.
The survey also highlights the connections between stunting prevalence and other socioeconomic factors such as the education level of mothers, rural landscape, and household income, among others, besides the obvious play of nutrition. Even the calorie deficiency of a household is impacted by socioeconomic determinants such as age and educational status of the household head, annual per capita expenditure of the home, the share of food grain distributed through the Public Distribution System (PDS), the type of occupation of the family members, their access to formal credit, their ownership of land and livestock, and dietary diversity of the food they consumed.
Considering the plethora of factors stated above, it is thus unsurprising that the progress in controlling stunting was decelerated in India during the pandemic as this created an insufficient environment for childcare and development.
Efforts for prevention
The Government of India tackles the challenge of malnutrition, which often leads to stunting, through a comprehensive policy structure. Their policies encompass a wide range of objectives, including improving the nutritional status of children, enhancing enrolment rates and attendance in schools, and addressing the prevention, identification, and management of child malnutrition. Additionally, they strive to reduce gender inequalities, promote healthy environments and nutrition in villages, ensure access to clean water and sanitation facilities, provide pre- and postnatal care, facilitate vaccination programs, and combat communicable diseases. POSHAN Abhiyan’s progress report recommends improving breastfeeding through behaviour change, investing in girls’ education, sanitation, and other interventions to help avert stunting cases.
National health programs such as the National Nutrition Mission and Universal Immunisation Program, aim to reduce stunting, undernutrition, anaemia, and low birth weight babies by creating synergies, to ensure better monitoring, the issuing of timely alerts, and encouraging states/union territories to perform, guide, and supervise the line ministries.
Exemplifying the efforts of certain states, Jharkhand succeeded in reducing stunting cases by focusing on the nutrition of adolescent girls and pregnant women by providing the proper intervention at the right age. In Bihar, Anganwadi centres have been modified as e-learning centres for children and enrolled migrant workers to provide nutritious food (such as milk and eggs), and improved complementary feeding.
What impacts a child’s development?
Is nutrition, although a significant part of a child’s development, the only factor that needs to be focused upon for the child’s overall development? Although the various government initiatives and policies concentrate on multiple aspects of child health via their individual strategies, the stubborn challenge of stunting still prevails. It presents the scope to rethink a child’s first 1000 days of life and several other facets of a child’s daily life which impact their overall development.
Beginning from the inception, their genetics are decided, with parental factors determining their epigenetics that dictate the expression of genetic profiles. Right after birth, the child’s gut is rapidly occupied by microorganisms from their mothers and the surrounding environment. The child develops a symbiotic relationship with the microbes, the presence of which contributes to how they fight disease, digest food, and may even impact their psychological processes. Diseases and malnutrition in the first 1000 days (about 2 and a half years) can affect the colonisation of the infant’s gut microbiota and delay its maturation. Moreover, depending on the child’s appetite, nutrition, epigenetics, immune system responses, or infections, there remains a risk of parasitic infections. The food and environment children grow in, massively influence their development, playing a crucial role for those living in resource-limited countries. These include the Water, Sanitation and Hygiene (WASH) practices, behavioural determinants of infant feeding, hygiene and caregiving practices, and their domestic environment. The cultural and local values-based perceptions of matters involved in child growth are also essential. All these factors together determine the growth and development of the child, and impact their performance in education, cognition, and development.
Addressing the issue
While tackling stunting, a highly nutrition-focused approach which not only drives multisectoral synergies, but also crosses intergenerational barriers, is essential to producing long-term impact to achieve certain milestones. Whilst grasping the shape and structure of the mosaic that is child health, crucial questions to be asked include: What is the cascade of factors driving child stunting? What are the synergies and inter-relationships between drivers? What are the critical points along this cascade where healthy linear growth diverges to slow or no growth?
To seek solutions to such questions, gain scientific insights into the interdependencies involved, and drive policy action towards a synergistic multisectoral approach, the Action Against Stunting hub, funded by the UKRI GCRF, works with 17 partner institutions and across three countries: India, Senegal and Indonesia. The hub in India collaborates with two institutions, ICMR-National Institute of Nutrition and Indian Institute of Public Health- Gandhinagar, with Dr Bharati Kulkarni as the country lead.
The research emerged with the aim of shifting the focus of prior investigations on child stunting, which predominantly examined isolated components of the problem. Instead, the Hub emphasises the exploration of the distinct individual elements that collectively shape the holistic concept of the ‘whole child’. In other words, the Hub’s research prioritises understanding the biological, social, environmental, and behavioural context of stunting and the synergies and inter-relationships between drivers.
To this end, the research being conducted aims to understand the ‘bio-developmental’ niche governing child growth, focusing on the interaction between the child’s biological, physical, and social environment. Through this approach, stunting prevention can be refocused on the complete tapestry of a child’s development, focusing on under-nutrition as an outcome of four inter-linked ‘environments’ radiating from the physical to the immediate/home environment, educational settings, and the broader food system. These domains linked by social values directly shape a child’s lived experience and can better help in optimising the conditions to ensure every child can reach their full potential in life.
In applying this paradigm, the path ahead is clear: we must radically change our perspective from the related parts to that of the Hub’s ‘Whole Child Approach’ (WCA). Such an approach involves the collaboration and coordination of various sectors amalgamating into a multisectoral array of practice, policies, and programs designed and implemented in a coordinated manner. For example, policies that promote access to nutritious foods involve collaboration between the health and agriculture sectors. In contrast, policies that promote early childhood education can include collaboration between the education and social protection sectors.
Summing up
To effectively address the needs of children in a culturally diverse landscape such as India, policies and actions must be designed considering the specific cultural, social, and economic context. This requires engaging with communities and understanding their needs and perspectives. For example, policies promoting access to clean water and sanitation should consider the specific challenges and barriers to access in different communities. Similarly, policies promoting early childhood development should consider the cultural norms and practices that influence child-rearing in other regions of India.
Finally, integrating the WCA into multi-sectoral policies and actions in India requires the engagement and participation of stakeholders at all levels, including policymakers, healthcare providers, educators, community leaders, and families. Stakeholder engagement can ensure that policies and programs are designed and implemented in a manner that is culturally appropriate, context-specific, and responsive to the needs of children and families.
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