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Recently, the 2020 Global Nutrition Report was released. It throws light on the progress made so far and the existing challenges. This Report comes at a time when the world is suffering from a pandemic. Even though, the Global Nutrition Report (GNR), 2020 was written before the COVID-19 pandemic, it holds a significant value in the present times. It focuses on the need for a more equitable and sustainable food and health system. The GNR points out inequity as the primary cause of the concern. It states that inequity causes malnutrition, undernutrition, overweight, and other diet-related diseases. It further states that when there is inequity in the food and health system, it gives rise to “inequalities in nutrition outcomes”. This in turn gives rise to even more inequity, thus, giving birth to a never-ending vicious cycle.
“COVID-19 does not treat us equally”—this is the true position of the impact of this pandemic. It has severe effects on that section of the society that is already vulnerable. Undernutrition leads to weaker immune systems making such people more susceptible to the disease. Poor, women, children, refugees, minorities, people from conflict-ridden areas are some examples of the various vulnerable sections of the society who will suffer the worst at the hands of the global pandemic.
The 2020 Global Nutrition Report brings focus on the need to integrate nutrition into universal health coverage. An improvement in the diet will go on to reduce healthcare expenses and also save lives. We need a system that ensures that no one is left behind. Apart from malnutrition, the GNR also highlights the problem of obesity and how it makes people spend serious money on healthcare as well as renders them at risk from COVID-19.
The GNR 2020 calls for an “action on equity to end malnutrition”. It assesses the link between malnutrition and the different forms of equity. It also expresses that the challenges brought by the COVID-19 pandemic must be turned into opportunities.
Where does India stand in it?
GNR 2020 is an indicator of the progress made by countries towards the eight out of ten nutrition targets. It places India amongst the 88 countries that are going to miss the 2025 global nutrition targets. The high rate of domestic inequalities persisting in our country is one of the main reasons behind this unsatisfactory position in the global nutrition index.
According to GNR, India will be missing out on all 4 targets including anemia, and low birth weight among others. The report identifies the following important points concerning India:
- One in two women of reproductive age is anemic
- Stunting is seen in one in three children less than five years of age.
- One in five children under five years is wasted.
- Rates of obesity in women reach 20.7% while in men it is 18.9%
- The data from rural and urban areas show the prevalence of inequalities in nutrition.
- The highest stunting rate is from Uttar Pradesh with more than 40% and a higher rate of stunting.
- The report also observed that the stunting prevalence is more in rural areas compared to urban areas, at the rate of 10.1 %.
- The rates of underweight have seen a decrease between 2000 and 2016. It came down from 66% to 58.1% for boys and from 54.2% to 50.1% for girls. This is, however, still high when compared to the average rate of the whole of Asia.
The Global Nutrition Report was first conceived in 2013 as a result of the first Nutrition for Growth Initiative Summit (N4G). It is an annual report that first came out in 2014 and has since then emerged as the “world’s leading independent assessment on nutrition”. Before this report in 2012, the World Health Assembly identified six global targets on six nutrition needs. They are:
- Childhood stunting: Reducing stunting by 40% in children under 5 years age;
- Anemia: Reducing anemia by 50% among women in the age group of 19-49 years;
- Low birth weight: Ensuring a 30% reduction in low-birth-weight;
- Childhood overweight: Ensuring no increase in childhood overweight;
- Exclusive breastfeeding: Increasing the rate of exclusive breastfeeding in the first six months up to 50% at least;
- Childhood wasting: Reducing and maintaining childhood wasting to less than 5%
The governments of the respective countries are to focus on these targets to achieve better nutrition.
The GNR uses the latest data to track global progress and uses it as a comparison for country-specific progress. The rules for assessment are determined with the help of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). These rules are then used to monitor the progress towards achieving the aforementioned six nutrition targets.
Average annual rate of reduction: The average annual rate of reduction (AARR) is calculated to check the change in percentage in the prevalence of any of the targeted indicators. The required AARR is the value that a country needs to achieve its targets. The current AARR is the actual achievement. These two calculations help in determining whether a country is on track to achieve its targets or not.
Law/policies regarding nutrition in India
The government of India recognizes nutrition as a multi-sectoral issue. So, to ensure coordination, the National Nutrition Policy sought to establish an inter-ministerial coordination committee. However, its progress is limited. The National Nutrition Policy was one of the first policies in India regarding nutrition. It came out in 1993 and laid down the foundation for the upcoming nutrition laws and policies. It also adopted a multi-sectoral approach to tackle malnutrition and ensure apt nutrition for all.
Some other laws and policies regarding nutrition in India include:
- The National Nutritional Anemia Prophylaxis Programme (1970)
It focuses on children of ages 1 to 5 years and pregnant and nursing mothers. It aimed to decrease the incidence of anemia in women (of reproductive age, pregnant, lactating women) and pre-school children. It is implemented through primary health centers and sub-centers. It promotes the consumption of iron-rich foods, supplies iron and folic acid (IFA) supplements, and identifies and treats severely anemic cases.
- Integrated Child Development Services (1975)
This scheme is one of the world’s largest programs that provide integrated services aimed at the development of children. It was launched to meet the needs of nutrition, immunization, and preschool education. The services under this scheme are implemented by the Anganwadi Centres through Anganwadi workers. This scheme has been successful in taking the benefits to the grassroots level.
- National Plan of Action on Nutrition (1995)
In 1995, the National Plan of Action on Nutrition was launched. It can be said to be the subsidiary action plan of the National Nutrition Policy that came in 1993. The plan focuses on reducing undernutrition. It entails a multi-sectoral approach for accelerated action on dealing with the various factors responsible for malnutrition.
- Mid-Day Meal Scheme (1995)
It was launched in 1995. Under this scheme, all the students of government and government-aided primary schools were entitled to receive a prepared mid-day meal. This scheme received a further extension in 2002 when it also took within its cover the children studying in Education Guarantee Scheme (EGS) and Alternative and Innovative Education (AIE) Centres. This scheme not only ensured the attendance of children in primary schools but also took care of their dietary needs.
- National Rural Health Mission (2005)
It was launched by the then Prime Minister in April 2005. The main aim of its introduction was to ensure affordable access to quality health care in rural areas. Based on this mission, the Union Cabinet approved the launch of a sub-mission namely, the National Urban Health Mission in 2013.
- National Food Security Act (2013)
This Act came in force in 2013 and was drafted to provide basic food and nutrition security to the people of this country. It takes within its ambit about two-thirds of the Indian population. It ensures that wheat and rice are available to the beneficiaries at affordable prices. The Public Distribution System is responsible for such distribution.
- National Health Policy (2017)
This is the third National Health Policy to be announced. The first one was launched in 1983 while the second in 2002. The goal of the third policy was set to be as per the current times and its needs. It sought the “highest possible level of health and wellbeing” for people of all ages. Its main objective was to gain and embolden the trust of a common man in the nation’s health care system.
The judiciary, over the years, has had a varied instance on whether the right to food comes within the ambit of Article 21, right to life of the Constitution of India. However, Article 47, a directive principle, casts a duty on the State to ensure that a standard level of nutrition is available to all its citizens.
Law/policies regarding global nutrition
The right to nutrition derives from the right to adequate food and the right to the highest attainable standard of health, as set out in the Universal Declaration of Human Rights, 1948. It was subsequently adopted in the International Covenant on Economic, Social and Cultural Rights (CESCR), 1966 in Articles 11 and 12. General Comment No. 14 of the Committee on Economic, Social, and Cultural Rights reaffirmed the nutrition dimension of the right to health. This was through an express statement that nutrition is one of the underlying determinants in the achievement of the highest attainable standards of physical and mental health.
Nutrition forms an explicit part of the right to health and the right to adequate standards living in other international treaties, such as the Convention on the Rights of the Child (CRC), 1989, the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW), 1981, Peoples’ Rights on the Rights of Women in Africa, 2003, and the Protocol to the African Charter on Human and Peoples’ Rights.
The African Regional Nutrition Strategy 2016-2025 highlights that each of the conditions of nutrition, i.e., food and healthcare, are necessary. But they cannot achieve optimal nutrition individually. It highlights the need for multi-sectoral approaches, coordination, and improved accountability and governance. The Regional Strategy aligns itself with the Scaling Up Nutrition (SUN) movement. SUN advocates for increased investments in context-specific, cost-effective, nutrition-sensitive, and nutrition-specific interventions. This can be achieved through advocacy, responsible nutrition governance, and private sector engagement. It offers direct assistance to countries including many African countries with policies and projects that bring authorities together to enhance the nutrition of the society.
Scope of improvement
The nutrition requires management through direct as well as indirect endeavors. Policies to strengthen sustainable agriculture and smallholder farming must be coupled with action to diminish food wastage and loss. This can go a long way in ensuring the safety of the food system and availability to consumers. Increased consumption of fresh fruit and vegetables and a decreased consumption of nutrition-poor processed foods require promotion and support from policymakers.
Investing in clean drinking water and sanitation will also have a strong impact on nutritional outcomes. Similar would be the case with increased access to primary health care that gives special attention to the nutritional status of children, teenage girls, and women of reproductive age.
The Pan-African Vision for Environment already provides a framework for policy interventions in nutrition. These can be built on for legislative interventions. It is noteworthy that the present need is for a combination of interventions, both general and specific to nutrition. There is also a need to redouble efforts if the nations want to see better nutrition outcomes in the future and the attainment of the Sustainable Development Goals.
Various measures in the area of food law to improve the nutrition scope are as follows:
- Food safety and quality legislation that facilitates coordination among all stages of the food production chain.
- Specific labeling schemes to provide consumers with essential information on the nutritional contents of food, nutrition guidelines, etc.
- Nutritional control on marketing, including regulation of food and snacks around school premises and public institutions and advertising and marketing aimed at children.
- Regulations related to food fortification to prevent and address micronutrient deficiencies e.g. adding iodine, iron and some vitamins to salt and staple food
- Regulations on specific food ingredients such as salt, fats, and sugar content in processed foods.
- Restricting the marketing of breast milk substitutes per the WHO International Code of Marketing of Breast-Milk Substitutes.
Legislating for nutrition has considerable complexity, as it includes a variety of issues. Countries may need to consider the varying needs and goals based on their population and the root causes of malnutrition. In rural areas, where only limited types of food may be available, issues such as water supply, sanitation, school education, health care system, affordable access to adequate food, quality of such food may be significant. Food safety and quality, labeling, food composition, for example, salts, sugars, and fats in processed foods, maybe the priorities in urban areas.
The Global Nutrition Report 2020 presented its annual findings showing the world a stark and bitter reality. When the world has been hit by a pandemic that is bent on testing the potentials of the health care systems, the findings of this report become even more significant. We are only as strong as our weakest link. The United Nations and WHO both have taken this approach and have constantly urged the nations to look after their vulnerable groups. Developed nations were also urged to help out the vulnerable countries. It is in these times that the GNR 2020 tells us that as many as 88 nations are not on track to achieve any of the 4 nutrition targets by 2025 as opposed to 8 who are on track.
It has already been established that people who are already vulnerable will be the worst hit. Lack of apt nutrition renders the immune system weak thus making undernourished, underweight, and malnourished people susceptible to severe illness due to the coronavirus. The current world pandemic has brought forward the existing issues with the health care system across the world as well as the nutrition policies.
The GNR 2020 has gone beyond national and global data. It has also brought forth the persisting inequalities that have led to malnutrition and other such chronic nutrition-related diseases. Now, this report can only reveal the current situation in terms of weak spots and progress. At most, it can also provide a broad framework that can help achieve the nutrition targets. But, the real work has to be done by the nations.
Specific nutrition laws that are also well-integrated with other policies are the need of the hour. Although it is not recommended that a single nutrition law should be implemented. This is because nutrition-related issues form part of various legislative areas and bringing them all into one single law could lead to confusion. Some distinct entry points can be established across a variety of applicable legal areas to improve nutrition. For instance:
- Social protection legislation and minimum wages to enhance the ability of consumers to purchase adequate, nutritious food.
- Strengthen legislation on gender equality and women’s empowerment.
- Enact laws that help keep girls in schools, such as a gender-sensitive law on school food and nutrition and free education at primary and secondary school levels.
- A law requiring the integration of nutrition education in the school curriculum.
- Ensuring concerted and coordinated action by assigning institutional responsibilities, providing for budgetary and other commitments.
- Use pricing incentives through taxes, subsidies to promote the consumption of fresh products.
As regards India, its current position in GNR 2020 is pathetic and hence requires quick and efficient measures. After analyzing all the factors, it can be said that one of the main reasons behind nutrition-related issues in India is the lack of a multi-sectoral coordination structure. Despite various nutrition policies in place, India is still very far from achieving its 2025 targets. One solution can be to borrow from the best practices of countries that have made significant progress in combating malnutrition and other related diseases. There is enough evidence from such countries that a multi-sectoral framework provides tangible results. India’s problem has always been of implementation. Thus, it needs stringent measures in place.
Global and national trends mask significant inequalities within countries and populations, the most affected being vulnerable groups. The report found clear links between malnutrition levels and characteristics of the population such as location, age, sex, education, and wealth, while conflicts and other forms of fragility compound the problem. The Report calls for a shift in food systems as current agricultural systems tend to concentrate on staple grains such as rice, wheat, and maize, rather than cultivating a broader variety of more varied and healthier foods such as fruit, nuts, and vegetables.
Solutions have begun to emerge across the world and are being introduced by an increasing number of countries, including India, Nigeria, Peru, and Thailand. These include, greater public investment in healthier products, support for shorter supply chains for fresh food delivery schemes, use of fiscal instruments such as sugar-sweetened beverage taxes, restricting junk food ads, and reformulation of food.
Authors: Swathi Ashok Nair from Cochin University of Science and Technology and Umang Dudeja from IMS Unison University.
Editor: Shalu Bhati from Campus Law Centre, Faculty of Law, University of Delhi.