Malnutrition in India: status and government initiatives

Abstract

Malnutrition, according to the World Health Organization (WHO), refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. It is well-known that maternal, infant, and child nutrition play significant roles in the proper growth and development, including future socio-economic status of the child. Reports of National Health & Family Survey, United Nations International Children’s Emergency Fund, and WHO have highlighted that rates of malnutrition among adolescent girls, pregnant and lactating women, and children are alarmingly high in India. Factors responsible for malnutrition in the country include mother’s nutritional status, lactation behaviour, women’s education, and sanitation. These affect children in several ways including stunting, childhood illness, and retarded growth. Although India has nominally reduced malnutrition over the last decade, and several government programs are in place, there remains a need for effective use of knowledge gained through studies to address undernutrition, especially because it impedes the socio-economic development of the country. These findings may provide useful lessons for other developing countries that are working towards reducing child malnutrition in their settings.

Full text

J Public Health Pol
https://doi.org/10.1057/s41271-018-0149-5
VIEWPOINT
Malnutrition inIndia: status andgovernment
initiatives
JitendraNarayan1· DennyJohn2,3· NirupamaRamadas4
© Springer Nature Limited 2018
Abstract Malnutrition, according to the World Health Organization (WHO), refers
to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutri-
ents. It is well-known that maternal, infant, and child nutrition play significant roles
in the proper growth and development, including future socio-economic status of
the child. Reports of National Health & Family Survey, United Nations International
Children’s Emergency Fund, and WHO have highlighted that rates of malnutrition
among adolescent girls, pregnant and lactating women, and children are alarmingly
high in India. Factors responsible for malnutrition in the country include mother’s
nutritional status, lactation behaviour, women’s education, and sanitation. These
affect children in several ways including stunting, childhood illness, and retarded
growth. Although India has nominally reduced malnutrition over the last decade,
and several government programs are in place, there remains a need for effective use
of knowledge gained through studies to address undernutrition, especially because it
impedes the socio-economic development of the country. Thesefindings maypro-
vide useful lessons for other developing countriesthat are working towards reducing
child malnutrition in their settings.
* Jitendra Narayan
jitunarayan@gmail.com
Denny John
djohn1976@gmail.com
Nirupama Ramadas
nirupama@scbt.sastra.edu
1 Department ofHealth Research, Ministry ofHealth andFamily Welfare, IRCS Building, Red
Cross Road, NewDelhi, India
2 Campbell Collaboration, NewDelhi, India
3 ICMR-National Institute ofMedical Statistics (NIMS), NewDelhi, India
4 School ofChemical andBiotechnology, SASTRA University, Thanjavur, TamilNadu, India

J.Narayan et al.
Keywords Malnutrition· Children· India· Nutrition programs· Public health
Introduction
Malnutrition in children is a public health problem in many developing countries.
Apart from great human suffering, both physical and emotional, it is a major drain
on the prospects for development in these countries. Why? Mainly because malnour-
ished children require more intense care from their parents and are less physically
and intellectually productive as adults. Being malnourished is also a violation of a
child’s human rights. Lessons from the causes, and fromgovernment initiatives to
manage and reduce child malnutrition in emerging economies, such as India, should
be useful for other such countries wishing to diminish child malnutrition at home
and to improve public intervention strategies.
In the South Asian region, India is one of the fastest growing countries eco-
nomically, educationally, and technologically. Despite economic progress, India has
failed to combat malnutrition that adversely affects the country’s socio-economic
progress. More than one-third of the world’s malnourished children are in India.
Half of the world’s malnourishedchildrenreside in3countries: Bangladesh, India,
and Pakistan [1].
Accordingto the Global Hunger Index 2017,India ranks 100 out of 119 coun-
tries. The prevalence of malnourished children in India is nearly double that in
Sub-Saharan Africa and affects the mortality rate, productivity, and economic
growth.Each year, nearly half of childrenin India are malnourished and almost a
million children die before reaching one month of age.In India, 43% of children
under 5years are underweight and 48% are stunted, due to severe malnutrition (3
out of every 10 children are stunted) [2].
Based on comparison of data from the Fourth National Family Health Survey
(NFHS-4) and theThird National Family Health Survey (NFHS-3) in the National
Nutrition Strategy report of National Institution for Transforming India (NITI),
Aayog reports a decline of underweight prevalence in children under 5years in all
states and Union Territories (except Delhi), although absolute levels remain high
[3]. Lim et al. report that in the year 2010, about 1.5 million women and chil-
drendied from problems associated with malnutrition [4]. Estimates in data from
Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutri-
tion in India (POSHAN) suggest that 309,300 babies die the day they are born, and
876,200 babies die during their first month of life, from causes involving low birth
weight, underweight, and iron deficiency [5]. Agarwal and Sethi, estimated, in the
year 2012, 1.6 million children died before reaching age 5 [5].
Although the Integrated Child Development Services (ICDS) scheme mandates
nutrition education, along with other services, to pregnant and lactating women
through its frontline workers, analysis of District Level Household Survey (DLHS)-3
data shows that the proportion of women who received nutrition and health educa-
tion from an ‘Anganwadi worker’ (see Box1) during their pregnancy and lactation
is low [6].

Malnutrition inIndia: status andgovernment initiatives
Box1: Glossary
Anganwadi Centres (AWC ) Anganwadi is a type of rural child care centre in India started by the Indian
government in 1975 as part of the Integrated Child Development Services (ICDS) program to combat
child hunger and malnutrition. Anganwadi means “courtyard shelter” in Indian languages. Angan-
wadi centres provide basic health care activities including contraceptive counselling and supply,
nutrition education and supplementation, and preschool activities.
Anganwadi Workers (AWW ) Anganwadi workers support and execute activities of Anganwadi centres.
They offer education about nutrition, especially among pregnant women, including how to breast
feed. They also inform parents about family planning and child growth and development. They keep
track of beneficiaries, especially those categorised as malnourished.
Panchayat Raj Institutions (PRI) Panchayati Raj is the basic unit of administration in a system of
governance. India’s Constitutional (73rd Amendment) Act 1992 came into force on 24 April 1993 to
provide constitutional status to the Panchayati Raj institutions.
Accredited Social Health Activists (ASHAs) are community health workers instituted by the Govern-
ment of India’s Ministry of Health and Family Welfare (MOHFW) as part of the National Rural
Health Mission (NRHM). ASHAs are local women trained to act as health educators and promoters
in their communities.
Auxiliary Nursing Midwife (ANM) is a village level female health worker in India. She is the first
contact person between the health services and community. ANMs play a very prominent role in
providing effective health care and facilities to village communities.
Antenatal Care (ANC) is care provided by health professionals during pregnancy.
Postnatal Care (PNC) is the care given to amother and a new born baby from birth through 6 weeks of
age.
Pradhan Mantri Matru Vandana Yojana (PMMVY) is the Maternity Benefit Programme implemented
by Government of India.
Nutrition plays a critical role in healthy growthand development(physical and cog-
nitive)and socio-economic statusof the child and is the key togood health. Mal-
nutrition threatens the long-term human development and may interfere with cog-
nitive development [7] and adulthood labour productivity in the families whose
resources place them below the poverty line [8, 9]. Thus, poor nutrition, especially
for those with low resources, poses a seriousthreat to the socio-economic status of
the country.
Classification ofmalnutrition
According to the World Health Organization (WHO), ‘malnutrition’ refers to defi-
ciencies, excesses, or imbalances in a person’s intake of energy and/or nutrients
[10]. It can be either ‘undernutrition’ or ‘overnutrition’. Symptoms of malnutri-
tioninclude physical and mental exhaustion,lowweight in relation to height(wast-
ing)and shortness for age(stunted),diminishedskinfolds, exaggerated skeletal con-
tours, and loss of elasticity ofskin. (See Table1 for the classification used to assess
the severity of malnutrition among children under 5years of age.)
The WHO Global Database on Child Growth and Malnutrition uses a Z-score
cut-off point of < − 2 SD to classify low weight-for-age, low height-for-age, and low
weight-for-height as moderate and severe undernutrition, and < − 3 SD to define
severe undernutrition. The cut-off point of > + 2 SD classifies high weight-for-height
as overweight in children.
The most widely studied malnutrition consequences include marasmus and
kwashiorkor, both consequences of lack of proteins and energy. Protein–calorie

J.Narayan et al.
malnutrition (PCM) occurs as marasmus (characterised by growth failure and wast-
ing) and as kwashiorkor (only protein deficiency), characterised by tissue oedema
and damage. Both kwashiorkor and marasmus are common in infancy and child-
hood when dietary essential amino acid content is insufficient to satisfy growth
requirements. Kwashiorkor typically occurs at about age 1, after infants are weaned
from breast milk to a protein-deficient diet of starchy gruels or sugar water, but
it can develop at any time during the formative years. Marasmus affects infants
aged 6–18months as a result of breastfeeding failure or when there exists chronic
diarrhoea.
Factors responsible formalnutrition
Various factors play pivotal roles in causing chronic malnutrition in children. One of
the most important is the mother’s nutritional status. About 36%of the population
of women are underweight,and56% of women and 56% of adolescent girls between
15 and 19years old suffer from iron deficiency anaemia due to undernourishment
in India [11]. A staggering 75% of new and adolescent mothers are anaemic and
most put on less weight during pregnancy than they should—only 5kg on aver-
age,compared to the worldwideaverageof close to 10kg [4]. Between 2005–2006
and 2015–2016, there was an average decrease of only 3.5 percentage points in
iron deficiency anaemia. Eight states failed to reduce their burdens (Delhi, Hary-
ana, Himachal Pradesh, Kerala, Meghalaya, Tamil Nadu, Punjab, and Uttar Pradesh)
[12].
Data on anaemia showed that 56% of girls and 30% ofboys aged 15–19years
were anaemic [13].Menstrual blood loss makes adolescent girls more vulnerable
to the problem of iron deficiency anaemia (IDA). This gender difference results
from gender inequality that is seen even in middle-income families, though it is
more prevalent in poorerfamilies.Adolescent girls are less likely than boys to con-
sume food rich in proteins, vitamins, and micronutrients [14].The NHFS-4 reported
only 2% decline of iron deficiency anaemia among women from 55% in 2005–2006
to 53% in 2015–2016, with 51% and 54% women with anaemia in urban and rural
areas, respectively. And in 8 states, over 60% of womenwere anaemic [15].Anaemia
in children under 2years of age affects brain function and folatedeficiency causes
neural tube defects [16].
Pregnant women and lactating mothers suffer most frommalnutrition and this
may be the cause of prematurity and low birth weight babies. Studies indicate
Table 1 Classification
for assessing severity of
malnutrition by prevalence
ranges among children under
5years of age
Indicator Severity of malnutrition by prevalence ranges
Low (%) Medium (%) High (%) Very high (%)
Stunting < 20 20–29 30–39 ≥ 40
Underweight < 10 10–19 20–29 ≥ 30
Wasting < 5 5–9 10–14 ≥ 15

Malnutrition inIndia: status andgovernment initiatives
a close association of maternal nutritional status with the well-being of a child.
Women malnourished in childhood due to poverty or gender inequality are most
likely tohaveunhealthy babies [16, 17].According to UNICEF data, one-third of
women in India in their reproductive period are malnourished and give birth to mal-
nourished babies; this pattern perpetuates through generations [18].
In India most mothers lack knowledge about how to feed children to improve
nutritional status [19]. Growing evidence suggests that lack ofbreastfeedingor a
reduced breastfeeding period may lead to undernutrition in infants and children.
This is especially critical during the first 6months of a child’s life [20].Breastfeed-
ing increases immunity inbabies and research shows an association between limited
or no breastfeeding and death of children under 5years [21]. (Breastfeeding protects
against infections during and most likely after lactation, as well as possibly against
certain immunologic diseases, including allergy. A few factors in milk, including
anti-antibodies (anti-idiotypic antibodies) and T and B lymphocytes, together with
transfer of numerous cytokines and growth factors via milk, may add to an active
stimulation of the infant’s immune system. Consequently, the infant might respond
better to both infections and vaccines.) Short intervals between pregnancies also
contributes to nutritional deficiency in children [22]. Studies show that malnour-
ished girls, early marriage, and early conception contribute to malnourished babies
or low birth weight babies whoare less competent [23].
In developing countries, women’s educationplays a prominent role in reducing
malnutrition. Analysis of National Family Health Survey (NFHS)-3 data indicates
that education of women is directly proportional to reduction in the percentage of
malnutrition and early marriage [14]. Education has shown to significantly contrib-
ute to the reduction ofchildunderweight, from 43% to 15.5%in developing coun-
tries [24].
Another important contributing factor for malnutrition in India is poor sanitation.
It causes diseases including diarrhoea and malaria through pathogens, thusreducing
consumption of nutritious foods and resistance to disease in children. According to
World Health Organization estimates, 50% of malnutrition is due to diarrhoea or
intestinal infection given poor sanitation [25]. Defecating in the open may be one
of the reasons for intestinal infection apart from using contaminated water. In India,
approximately 620 million people use publictoilets or defecate outside [26]. Mal-
nutrition in childrencan be caused due to infection through drinking water as infec-
tions reduce the absorption of nutrients [27]. (Poor sanitation leads to possibility of
water pooling, which due to influx of garbage and refuse, becomes the perfect envi-
ronment for mosquitoes to breed and transmit malaria.)
Effects ofmalnutrition onchildren
As described earlier, the predominant effects of malnutrition
arelowweight, stunted growth, and muscle wasting.About 48% of Indian infants
under 5 years ofage are reported to suffer from stunted growth due to malnutri-
tion [28]. Malnutrition increases the risk for infectious diseases by weakening
the immune system and also impairs cognitive and motor functions in growing

J.Narayan et al.
children.These children die from childhood conditions like diarrhoea, andillnesses
includingtuberculosis, measles, pneumonia, and malaria. Studies show that the last
few months of gestation and first 2years of life after birth are critical for growth
anddevelopment of babies.The first 1000days (conception to 2years post-partum)
are considered a ‘window of opportunity’ for addressing malnutrition [29]. Severe
malnutrition is also known to influence metabolic and organ function as well as chil-
dren’s behaviour.Aboutone-thirdof deaths in children under age 5years are attrib-
uted to undernutrition [30, 31].India’s data for 2015–2016showed stunted growth
in 38% of children under 5years;21% to be ‘wasted’;36% to be ‘underweight’; and
58% between 6 and 59months to be anaemic [32].The Global Hunger Index 2016
Report showeda relationship between malnutrition andretardedgrowth [33].Mal-
nourished childrenare found tohavelowresistance to infection and are thus more
prone to diseases [34] that ultimately influence economic growth of the country.
Management
Many management measures have been already implemented by the Government
of India to address nutritional status including, reducing poverty,improvingsanita-
tion, fortification of foods with essential nutrients, enhancing women’s education,
andimprovingagricultural practices.
Article 47 of Indian Constitution states that “The duty of the state is to raise the
level of nutrition and living standards and to improve public health”. Because the
Indian Government has accorded high priority to malnutrition, it is implement-
ing several programs through multiple Ministries or Departments of the national
government, through StateGovernment or Union Territory Administration (Presi-
dent of India appoints an administrator or Chief Minister) to improvethe nutritional
situation inIndia.
Policy andprogrammatic initiatives
Among developing countries, India has been in the forefront fordeveloping national
food and nutrition databases (such as the Indian Food Composition Tables, 2017)
and undertaking research studies and surveys documenting agriculture, food, and
nutrition transitions. The country has also used the evolving knowledge and invested
in nutrition intervention programmes to (i) improve food and nutrition security of its
citizens, (ii) ensure that the ongoing food supplementation programmes provide suf-
ficient food to meet the energy/nutrients gap in vulnerable segments of population,
and (iii) improve ongoing nutrition interventions, converge existing programs and
introduce newer ones, all aimed at preventing, early detection, and effective manage-
ment of child undernutrition in the country. The following programs and schemes
have been implemented for improving nutrition and combatting malnutrition by the
Government of India.

Malnutrition inIndia: status andgovernment initiatives
Integrated child development scheme(ICDS)
One of the most comprehensiveschemes for child development, started by the
Ministry of Women and Child Development in 1975, is funded partly by the Cen-
tral government of India and partly by the UNICEF. Its aim is to provide food and
primary healthcare to preschoolchildrenunder 6years of age and to their moth-
ers. To implement it, India established ‘Anganwadi centres’ (see Box1) in rural
areas.India launched ICDS in accordance with the National Policy for Children
in India to fight malnutrition, ill-health, and to address gender inequality. Angan-
wadi centres provide immunisations, health check-ups, nutritious food, and infor-
mal education under this scheme, spending annually on average US$10–22/child.
Supplementary Nutrition is one of the six services provided under the ICDS.
It is intended primarily to bridge the gap between the Recommended Dietary
Allowance (RDA) and the Average Daily Intake (ADI). ICDS is provided to chil-
dren (6months–6years) and pregnant and lactating mothers.
In 2010, India launched another program, “Pradhan Mantri Matritva Vandana
Yojana (PMMVY)”. (Previously it was called “Indira Gandhi Matritva Sahyog
Yojana (IGMSY)”.) The Ministry of Women and Child Development (MWCD)
launched it as part of ICDS after the Evaluation of ICDS Report in 2011 called
for improving the nutrition of pregnant mothers [35]. This maternity benefit pro-
gram is a cash transfer scheme for pregnant and lactating women of 19 years
of age or above for the first live birth. It provides partial wage compensation to
women for wage-loss during childbirth and childcare. In 2013, India placed the
scheme under the National Food Security Act (2013) to provide a cash maternity
benefit of US$87. Studies suggest, however, that eligibility and other conditions
exclude a large number of women from receiving their entitlements [36].
There is need for the ICDS program to be redirected towards the younger chil-
dren (0–3years) and the most vulnerable population segments in states and dis-
tricts with greater prevalence of undernutrition. It would be prudent to consider
emphasising infant and young child feeding and maternal nutrition during preg-
nancy and lactation. Doing so could bridge the gap between the policy intentions
of ICDS and its actual implementation. Many of these gaps in the ICDS, includ-
ing the IGMSY, can be filled with a regular schedule of workshops and through
sensitisation to the importance of preschool nutrition, for the Anganwadi centre
staff, pregnant and lactating mothers, mothers with children under-5 years age
and school going children, and teachers of primary schools.
Mid‑day Meal Scheme (MDM)
In 1995, the Central Government started the National Programme of Nutritional
Support to Primary Education, popularly known as the Mid-Day Meal scheme
(MDM), to improve the nutritional status and enhance enrolment and school
attendance of children.Implementation of MDM hasbeen successful throughout

J.Narayan et al.
the country.The Public Report on Basic Education (PROBE) reported that the
mid-day school meal increased nutritional status ofschoolchildren [37]. How-
ever, it also called for a transparent administrative system and improvement in
cooking methods—mainly because many of the school mid-day meal contracts
were given arbitrarily to self-help groups or organisations without following due
diligence and the cooking methods varyacross the country.
National Health Mission(NHM)
Launched in 2005, the National Health Mission covers both the National Rural
Health Mission(NRHM)and National Urban Health Mission (NUHM) andaims to
enhance the health programmes and health service delivery, in both rural and urban
areas, by improving maternal, neonatal child and adolescenthealth,thuspreventing
diseases [38]. The Mission also has a component of ‘convergence’ (see discussion
below of a Convergence Action Plan) for addressing prevention, identification, and
management of malnutrition in children. It is being implemented by ICDS and the
Ministry/Department of Health & Family Welfare, Government of India. Most of
the primary health centres, however, face severe shortages of doctors and trained
para-medics, lack infrastructure, and lack supplies of many essential drug and vac-
cines [39].
National Food Security Act(NFSA),2013
Launched on 10 September 2013, the National Food Security Act (2013) is an Act
of the Parliament of India intended to provide subsidised food grains to approxi-
mately two-thirds of India’s 1.2 billion people [31]. Under the Act, beneficiaries
of the Targeted Public Distribution System (TPDS) are entitled to 5 kilograms per
person per month of cereals at subsidised prices (USD0.05/kgfor rice,USD0.03/
kg for wheat, and USD 0.02/kg for coarse grains).The TPDS covers 75% of the
ruralpopulationand 50% of the urban population.
Another program under this Act, the Antyodaya Anna Yojana (AAY), launched
in December 2000, provides support to populations with fewest resources. They
(known as the Poorest Families category) are entitled to receive 35 kg of food
grainspermonth at the subsidised rate under the scheme of AAY. This scheme is
less successful due to limited resources, an exponentially increasing population, lack
of infrastructure, operational inefficiencies, and poor performance of the public dis-
tribution system [40].
Village Health Sanitation andNutrition Committee(VHSNC)
The Government of India launched the National Rural Health Mission (NRHM)
in April 2005. The Village Health Sanitation and Nutrition Committee (VHSNC,
earlier known as Village Health and Sanitation Committee) is a major initiative to

Malnutrition inIndia: status andgovernment initiatives
decentralise and empower local people to improve sanitation and nutrition in vil-
lages. It allows ‘panchayats’ (village councils) to contribute to the governance of
health and other public services in villages. The VHSNCs monitor the work and
contribution of community health workers, such as Anganwadi Workers (AWW),
Accredited Social Health Activists (ASHA), and other public staff (from govern-
ment entities such as the Water and Sanitation department, Roads work, among
others) in order to maintain good sanitation and healthy environments in thevil-
lages.These government health staff work under the supervision and monitoring of
the PanchayatiRaj Institutions(PRI).
Members of a VHSNC require orientation about their roles and responsibilities,
technical aspects of health, nutrition, sanitation, and participatory processes related
to making plans and using funds. VHSNCs need assistance to plan effectively to
allocate their funds rationally among health, nutrition, and sanitation activities in the
community.
ASHAs and ANMs areresponsiblefor providing information on malnutrition sta-
tus ofchildren(under 6years of age) in their target areasto the committee.They are
also responsible for providing an interface between villagers and the public health
care system. And they are accountable for ensuring take-home rations for chil-
drenunder 3 years and for pregnant/lactating mothers. For children aged3–6years,
ANMs provide supplementary food and raise issues about lapses in supplies
of supplementary foodswith the committee (VHSNC). The VHSNC ensures that
the Anganwadi Centres (AWC)provide hot-cooked meals in accordance with set
norms [41]. There are no standard practices of regular food inspection and there is
need for food inspectors to upload online reports, along with pictures of products,
for monitoring the delivery of these meals to the higher authorities.
Food Safety andStandard Authority ofIndia(FSSAI)
Established by Government of India on 5 September 2008 under theFood Safety
and Standards Act, 2006, the FSSAI provides technical support and scientific advice
to the government for policy and programme on food safety and nutrition. It also
supplies micronutrients to fortify foods and trains school staff toprepare mid-day
meals tofortify the food for children. IntheGajapatiDistrict of Odisha State (India),
for example, FSSAI trains school staff tofortify rice with iron [42].
Rajiv Gandhi Scheme forEmpowerment ofAdolescent Girls
(RGSEAG) orSabla Scheme
The Ministry of Women and Child Development (MWCD) started implementation
of SABLA for the Government of India on 1 April 2011. SABLA is also known as
“Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG) [43]. Its
aim is to empower adolescent girls aged 11–18years by promoting awareness about
health, nutrition, adult reproductive and sexual health (ARSH), providing education
in life skills and family welfare. It also provides iron and folic acid supplements

J.Narayan et al.
(IFA) under Reproductive and Child Health (RCH-2) and National Rural Health
Mission (NRHM). SABLA replaced Kishori Shakti Yojana (KSY) (that aimed to
improve the health and nutritional status of girls in the age group of 11–18years)
and Nutrition Programme for Adolescent Girls (NPAG) (thatprovided 6kg of free
food grain to under nourished adolescent girls). The AWW need more frequent train-
ing and experience sharing exercises to learn from one another about overcoming
challenges, as the counselling components are quite demanding of their time [44].
Village Health Nutrition Day (VHND)
One day every month, ASHA, ANM, and AWW mobilise villagers, especially
women and children, at Anganwadi Centres (AWC) to meet health personnel to
learn about healthcare facilities and to gather information on maternal and child
health, nutrition, family planning, sanitation, and communicable diseases. This day
also provides opportunities to vaccinate children (including school dropouts), to
treat those with tuberculosis (TB) and other diseases, and to distribute condoms and
oral contraceptive pills as part of family planning. This day would also prove ben-
eficial to villagers if it could be strengthened to effectively deliver drugs, to ensure
prevention of communicable diseases, and to educate about family planning, growth
monitoring, care during postnatal period, water, and sanitation facilities. Improved
participation of Panchayat members could ensure greater community participation
thus contributing to its effectiveness. See Table2 for additional government pro-
grams to combat malnutrition.
Initiatives byNational Nutrition Mission programs forfuture
management
The government has approved a National Nutrition Mission (NNM) with a three-
year budget of USD 1289 million dollars from 2017 to 2018 [45]. NNM moni-
tors, supervises, fixes targets, and guides the nutrition-related interventions across
the Ministries. It will strive to reduce stunting, undernutrition, anaemia, and low
birth weight babies. It aims to create synergy, ensure better monitoring, issue alerts
for timely action, and encourage States/UTs to perform, guide, and supervise the
line Ministries and States/UTs to reach the goals. More than 10 million people are
expected to benefit. All the States and districts will be phased in: 315 districts in
2017–2018, 235 districts in 2018–2019, and the remaining districts in 2019–2020.
The strategy for implementing this begins at the grassroots level and is based on
intense monitoring for compliance with the Convergence Action Plan. The Con-
vergence Action Plan aims to link the various services provided at different growth
stages of pregnancy and early child life including the crucial intervention pack-
ages available for the first 1000days of childbirth and pre and post-delivery sup-
port to mothers provided by different Departments/Ministries (such as PMMVY,
ANC, PNC, Home visits of ASHA/AWW, Vaccination, etc.—see Glossary), and
also at State/Union Territory, District, and Block levels. NNM has three phases

Malnutrition inIndia: status andgovernment initiatives
Table 2 Various governmental schemes in India
Sr. no. Schemes Objectives
(A) Pregnant and lactating mothers
1. Integrated Child Development Scheme (ICDS) Supplementary nutrition, counselling on diet, rest and
breastfeeding, health and nutrition education
2. Indira Gandhi Matritva Sahyog Yojana (IGMSY) Conditional maternity benefit
3. Reproductive Child Health (RCH-II) Antenatal care, counselling, iron supplementation,
immunisation, transportation for institutional delivery,
institutional delivery, cash benefit, postnatal care,
counselling for breastfeeding, and spacing of children,
etc.
4. National Rural Health Mission (NRHM)
5. Janani Suraksha Yojana (JSY)
(B) Children below the age of 3years
1. Integrated Child Development Scheme (ICDS) Supplementary nutrition, growth monitoring, counsel-
ling health education of mothers on child care, promo-
tion of infant and young child feeding, home-based
counselling for early childhood stimulation, referral,
and follow-up of undernourished and sick children
2. Reproductive Child Health (RCH-II) National Rural
Health Mission (NRHM)
Home-based new born care, immunisation, micronutri-
ent supplementation, deworming, health check-up,
management of childhood illness and severe undernu-
trition, referral, and cashless treatment for first month
of life. Care of sick newborns, facility-based manage-
ment of severe acute malnutrition and follow-up
3. Rajiv Gandhi National Creche Scheme Support for the care of children of working mothers
(C) Children aged between 3 and 6years
1. Integrated Child Development Scheme (ICDS) Non-formal preschool education, growth monitoring,
supplementary nutrition, referral, health education,
and counselling for care givers

J.Narayan et al.
Table 2 (continued)
Sr. no. Schemes Objectives
2. RCH-II, NRHM Immunisation micronutrient supplementation, deworm-
ing, health check-up, management of illnesses, and
severe undernutrition
3. Rajiv Gandhi National Creche Scheme Support for care of children of working mothers
4. Total Sanitation Campaign (TSC), Nirmal Bharat
Abhiyan (NBA), Swachh Bharat Abhiyan
Household-level sanitation facilities
5. National Rural Drinking Water Programme (NRDWP) Availability of safe drinking water
(D) School going children aged between 6 and 14years
1. Mid-Day Meals (MDM), Hot-cooked meal to children attending school
2. Sarva Shiksha Abhiyan (SSA) Support knowledge dissemination on nutrition by
inclusion of Nutrition-related topics in syllabus and
curriculums for formal education, school health check-
up, mid-day meal
(E) Adolescent Girls aged between 11 and 18years
1. Rajiv Gandhi Scheme for the Empowerment of Ado-
lescent Girls (RGSEAG)
Kishori Shakti Yojana
Supplementary Nutrition, Iron Folic Acid supplementa-
tion, vocational training of adolescent girls
2. National Rural Health Mission (NHRM) Weekly iron and folic acid supplementation
3. Total Sanitation Campaign (TSC) Nirmal Bharat
Abhiyan(NBA)
Access to sanitation facilities
4. National Rural Drinking Water Programme (NRDWP) Access to safe drinking water
(F) Adults and communities
1. Mahatma Gandhi National Rural Employment Guaran-
tee Act (MGNREGA)
Employment Guarantee for 100days per financial year
for adult member of rural household
2. National Rural Livelihood Mission (NRLM) Poverty alleviation in BPL families through self-
employment
3. Targeted Public Distribution System (TPDS) Food subsidy for rice, wheat, etc.

Malnutrition inIndia: status andgovernment initiatives
Table 2 (continued)
Sr. no. Schemes Objectives
4. National Iodine Deficiency Disorders Control Pro-
gramme (NIDDCP)
Promotion of use of iodised salt
5. National Food Security Mission (NFSM) Increased production of rice, wheat, and pulses
6. Rashtriya Krishi Vikas Yojana (RKVY) Supports states for creation of infrastructure, essential to
catalyse the existing production of food grains

J.Narayan et al.
from 2017–2018 to 2019–2020. Its targets include reducing stunting, undernutrition,
anaemia(among young children, women, and adolescent girls) and low birth weight
by 2, 2, 3, and 2% per year, respectively. Although the target to reduce stunting is at
least 2% p.a., the mission would strive to achieve reduction in stunting from 38.4%
(NFHS-4) to 25% by 2022 [46].
Conclusion
Among the developing countries, India has one of the highest numbers of mal-
nourished children. Nearly half of allchildren in India are malnourished and each
year almost a millionchildrendie before one month of age.Many new mothers are
adolescents, most of whom are anaemic. Compared to the global average, these
mothers gain only half as much weight during pregnancy. Maternal andchildmor-
tality and malnutrition rates in India are also alarmingly high. Sixty million chil-
dren are too short for their ages and half of those aretoo thin (acutely malnour-
ished). Prevalence of undernutrition is still very high in India despite reduction,
according to UNICEF, from 40 to 29% between 1990 and 2009 [47]. In compari-
son with developing countries with similar health profiles India fares well in terms
of infant mortality rate (IMR) and under five mortality rate (U5 MR). India fares
poorly when underweight in under-5 children is used as an indicator for food secu-
rity with rates comparable to that of Sub-Saharan Africa. Over the last few years, the
Government of India has recognised this and has expanded, consolidated—and also
introduced various programs to combat child malnutrition. There still exist some
issues and challenges with these interventions. Even so, awareness of these interven-
tions and some lessons derived from them can be useful for countries that are poised
toimprove child malnutrition in similar settings.
Acknowledgements The authors would like to thank Ms. Aarti Khanna for proofreading assistance.
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Jitendra Narayan, Ph.D., is a Scientist C in the Department of Health Research, Ministry of Health
and Family Welfare in New Delhi, India.
Denny John, M.B.A., M.P.H., is an Evidence Synthesis Specialist, Campbell Collaboration, New Delhi
and Adjunct Scientist, ICMR-National Institute of Medical Statistics (NIMS), New Delhi, India.
Nirupama Ramadas, Ph.D., is a Research Scientist, School of Chemical and Biotechnology, SASTRA
University, Thanjavur, Tamil Nadu, India.