Sneha Rout is a nutritionist at the National Health Mission and has been working to eradicate malnutrition in tandem with discovering ways and medical philosophies to reinstate the “long-lost magic of food”. She enjoys reading and writing articles, short stories and poems in her leisure time.
THE GREAT INDIAN FOOD PARADOX
Nutrition was a top-priority for us not so long ago, simply because it meant survival. What went wrong then that today we struggle with under-nutrition as much as obesity – globally, and acutely? Exploring food as the social marker that paints itself in different hues amidst the vast cultural diversity of India challenging its functionality as a source of nourishment, public health nutritionist Sneha Rout engages with the flip side of Appetite, bringing in everything from well-intentioned brand ambassadors to TV dinners and the big trap of social status fuelling this phenomenon.
‘I will not bite even the slightest portion of that fruit unless you let me watch Chhota Bheem right now!’, shouts a four-year-old, covering his mouth in revolt.
Why is it that the childlike simplicities associated with food seem to have disappeared? Why has the relay run for healthy eating failed to be passed along as an inter-generational baton? Why are we losing to fast food marathons and artificial beverage sprints instead? As a public health nutritionist, I have often thought about these questions and I find that it often boils down to a faulty approach – attitudes that are inspired by the latest piece of information trending everywhere – responsible for the dangerous makeover for food. A review article by researchers Manu Raj & R. Krishna Kumar in the Indian Journal of Medical Research (November 2010), shows that obesity in Indian children and adolescents is an outcome of sub-optimal cognitive development at home, parental choices that modify child food preferences, dramatic societal changes, and rapid urbanization – all of which push forward the behavior that makes high caloric food abundant, affordable, available, and easy to consume with minimum preparation time.
It made me think back, about the history of food and its interesting journey, from the hunting-gathering age to what we do now to secure food. Isn’t it true that what’s common across people, from terrorists to politicians to beggars, are – irrespective of the proportions each one gets – the three timely meals? Food is the modern world’s motivation behind everything, one could argue – from 9-5 work slavery, edging migrants out, to saving oil-deep countries by sending in the troops, to unemployed youths affiliating themselves as reformers. In the 1960’s, India was faced with severe food scarcity and the Green Revolution was what saved it from a massive famine then. Scientists used advanced technology, high yield crops, chemical fertilizers, multiple cropping over traditional Indian farming methods to increase food grain production in order to feed starving millions. Lal Bahadur Shastri, the then Indian Prime Minister, called for its citizens with his ‘Jai jawaan jai kisaan’ slogan, urging the farmers to grow more than one crop a year, encouraging the common man to grow crops and vegetables in their backyards. These combined efforts made India self-sufficient as among the highest agricultural producers. The Green Revolution was, for better or worse, an emergency response then; its merit debated ever since, questioning if it led to increased usage of fertilizers, which over a period of time, was also responsible for irreversible changes in the soil’s texture and an overview of agricultural practices in general. But have we, since then, devised initiatives to change the fact that India, according to the Global Hunger Index (GHI) Report, is home to one-third of the malnourished children in the world? Apparently things that have changed are the old standards of necessity that were defined as ‘roti-kapda-makaan’, or food-clothing-shelter. Shelter seems to have gained in importance because we, as a nation, went from buying a house as our pension goal to wanting one to stay in and another to rent. Employees at the Brihanmumbai Municipal Corporation, for instance, now rent their government quarters for they also have the option of shanties. Clothing too is a fad that has trumped over food in the triad of roti-kapda-makaan even in the most remote of Indian villages where people choose it even over availability of sanitation at times! The money-over food-shift got validated for me, I remember, when a beggar at Dadar station in Mumbai rejected the vadapav I offered him and instead asked for cash!
One cannot deny all the usual suspects when dealing with malnutrition: food insecurity, micronutrient deficiencies, neonatal and maternal illnesses, infectious diseases et cetera. But what is needed most urgently, is a socio-behavioral reinforcement along ith medical treatment – that is how the mammoth problem of malnutrition in India can be tackled effectively. It is time, I strongly feel, for the adults and not just the children to hear stories – perhaps not moon uncle odes – stories to figure out where and how they are getting it wrong. What we need is to make this necessity of food a resourceful tool of empowerment, emphasizing on education that makes nutrition every individual’s responsibility.
Behavioral studies on food are a neglected space, which shows how we are responsible for our own beliefs and how that in turn makes society bear the brunt of negative health outcomes. Since the power of stories and visual imagery hold a greater impact on masses, I developed sessions that I call narrative therapy to work with patients, to be used alongside the medical treatment and counseling. I started it as an experiment in 2013 at the Nutrition Rehabilitation Center (NRC) that I run under the National Health Mission in order to address the mindsets that lead to daily habits and the everyday regimes of people. Stemming from my on-field experiences, these sessions are aimed to raise interest and motivate beneficiaries with minimum literacy skills. Storytelling has the power to mould everyone’s thoughts, strengthen interpersonal parent-child bonds and thereby behavior, so I work with Tom and Jerry tales that go on to discourage excessive bottle feeding that leads to tooth decay and diarrhea, Mowgli and his banana chronicles and often recreate Chhota Bheem-Chutki adventures, using fruits and vegetables as disease fighting agents. Simple yet effective, these are all for the children. For the parents, I use patient case studies and raise questions such as: Has television become the new age mother from rural interiors to urban slums spoiling the young and old alike? Do parents need to take up the information wand that does the magic for their wards? Can knowledge be enough to change the staunch societal practices providing the much needed resuscitation our society needs? Can cash transfer schemes or food subsidies strike the right chord with people or has it reduced to a failed political intervention? The solutions to which participants arrive at themselves are later discussed in these sessions.
Ignorance though continues to play a big role in the common man’s day-to-day life: I remember this time, for instance, in Hirbandh, a little known block in Bengal where a child suffering from fever was brought to the health center. The child was weighed and found to be severely malnourished. But when the parents were asked to admit their child to the center, they refused and asked the doctors to only prescribe medicines for fever. ‘She will gain weight as she grows up,’ was their reasoning, demonstrating the belief that malnutrition did not even qualify, in their minds and imaginations, as an ailment that needed treatment. We would teach them the simple logic of how bad nutritional status leads to a compromised immune system thereby predisposing an underweight child to greater risk, always susceptible to infectious diseases. But the age-old adage of prevention being better than cure is no longer a popular argument and we are all adamant, it would appear, on working not on the foundation but on the outcomes – in getting modular diets for cardiovascular diseases, hypertension, diabetes, obesity. Surely, we can’t blame people alone when Madhya Pradesh, the state with the highest infant mortality rate (worse than underdeveloped countries like Kenya, Ethiopia, Ghana, and even Bangladesh and Nepal), has government officials who have failed to accept malnutrition as a public health concern.
Urban states fare slightly better. Working with the Foundation for Mother and Child Health, an NGO that works in Dhobi Ghat – a tourist destination in Mumbai known for its massive amounts of migratory populations – I met a caregiver who actually identified malnutrition as ‘Aamir Khan waali bimaari’ when she was asked about whether she understood what her child was suffering from! Although corrected later, she will remain forever etched in my memory for her unfortunate association of this epidemic as “a superstar’s disease” because of the star’s appearance in a malnutrition awareness campaign.
Malnutrition also has a high economic cost; a 1997 report of national strategies to reduce childhood malnutrition revealed that the cost of treating malnutrition is 27 times more than the investment required for its prevention. That reminded me of a mother at our rural supplementary feeding program in Dharavi, Mumbai, one of Asia’s largest slums, who would cite Salman Khan as a reference to her son to finish his milk. I also remember her consternation when the kid replied back, intelligently, of course, ‘Salman Khan drinks Thums up not milk, Mom!’ If only someone could put forth an endorsement proposal to Salman Khan, I wished then, where he would be jumping off terraces with a bottle of milk in tow, or kicking villains with his “secret power” of fresh fruits and vegetables. To appropriate the language of his movie reviews, it would absolutely be a million buck healthcare investment! Because today, food habits being passed down from the ancestors is passé – we need new superheroes. Another rural citing from a village Ranga in Bengal – I once had the parents of an underweight child come to me asking, ‘What’s the government offer for this, madam?’. I knew I had to admit the child before announcing the wage incentives attached to the government scheme –which they were interested in of course, along with the free ration coupons – but I first asked them to give me a dietary recall. They began by saying, ‘We are poor people, what can we feed?’ But a mere five minutes into the conversation, I managed to pull out from them how they enthusiastically fed a packet of biscuits to the child every morning. There were also chips sometimes, puffed rice, sugar candies, a glass of Horlicks on the meal plan and they both exclaimed their surprise at how the child had still not gained weight. When I proposed that they spend the same amount of money on a few low cost, high protein and nutrient-dense foods that are available locally, the parents were offended and retorted back, ‘Do you think we can’t afford the rich people’s stuff?’. In some ways, our society is stuck on the good food-rich people equation, even though one of the real culprits is not financial restrictions but rather availability and choice that are defining our nutrition pitfalls.
Past experience has shown us time and again that the belief of feeding people to help a section of people is a non-sustainable strategy and at best, a short term solution, with midway pilferages of corruption, unemployment. Ideally, empowering the population to become self-sufficient is the difficult but most optimum alternative to work towards. Citing from the National Sample Survey Organization (NSSO) data that shows how average families spend half their monthly income on non-food items, we can see how families buy 51% of non-food items monthly in rural areas and about 62% in urban. Every household prioritizes the presence of television and mobile phones over basic needs of food and sanitation. So shouldn’t the government focus too be on the importance of nutrition education rather than food subsidies to those who are on paper below the poverty line? I do not of course mean to imply that the rural poor have adequate resources, but they do have the right today, to choose local unauthorized junk and adulterated food items over good low cost nutritious foods because of the marketing boom and zero governmental interference. Streets outside government ICDS (Integrated Child Development Services) schools are lined with vendors offering ice pops and wafers, most of them packaged with toy indulgences (Chhota Bheem alert!) that can fill up children’s stomachs, even those with a few rupees at their disposal. Simultaneously there are many pockets in our country where there is still no availability of packaged milk, access to markets for fresh food, unrestrained pre-packaged food supply with no authentic labeling, which is why the malnutrition rates continue to rise.
An affluent Gujarati family in Mumbai that I encountered in my work drove home the food behavioral stigma for me: They brought in their daughter who had moderate malnutrition and the father gave me one of the best dietary recalls I have ever heard. He was very enthusiastic – which to me was a positive sign of a father taking interest in a child’s growth, and that too, a girl child – and said, ‘I give boiled eggs without yolk.’ My counseling on the demerits of that led to counter-arguments by the father who cited interviews of Bollywood celebrities stating the links between egg yolk and cholesterol, listing it as one of the reasons why they didn’t eat it anymore. I silently lamented the loss of Dara Singh for his ‘Sunday ho ya Monday roz khaao anday’ line, which was not on air as frequently as the processed food commercials due to the sheer lack of present day enthusiasts. And then he added, ‘And I also love Amitabh Bachchan, so I give her Maggi.’ (This was long before the Maggi controversy). ‘Maggi is my child’s favorite’, he continued, ‘she eats it every day as an evening snack. I give all the good things shown on television.’ My lecture on the evils of processed food was followed by an epic statement, ‘If Amitabh Bachchan can do it, then why do you say I should deprive my child with the luxury that I can afford!’ Food has indeed traveled the long distance from being a necessity to a status symbol, I knew it then!
Malnutrition, we must understand, is not a trending social cause that affects only famished kids in Africa just as obesity isn’t something that affects American kids alone. It’s a silent emergency that has already taken the form of an epidemic to be grappled with. This double burden is very much a reality, prevalent in India as a point of shame for a country that has splendid resources, ample food grain production, rising GDP, and some spectacular political leadership in recent years to boot. We can definitely try turning the tables on this topic of negligence, taking on individual responsibility of getting food and nutrition on the same page. With rapidly changing food dynamics, we must be sure that the right values sink in and that we do not blindly follow the herd. Wanting quick slimming results, popping in pills as vitamins, stirring up instant baby food mix – these are the modern day approaches towards the food-disease-treatment triad that’s gaining ground in both urban and rural areas, and they call for similar education patterns. Increasing our appetites for complete knowledge in order to transform lifestyles, is the need of the hour. For this we must realize food as our first tryst with learning – the fire-trial of raw to cooked, agriculture and settlements that we went on to boast of.