ProteinAid Bihar: Sustainable Nutritional Strategy for Children Under 5 Years Old

Summary 

India, despite substantial economic growth, still grapples with severe child malnutrition, with alarming rates of stunting and underweight particularly in regions like Bihar. This project aims to address these issues by promoting the use of plant-based proteins, such as legumes, to improve nutrition among children under five. Key activities involved selecting Bihar as the focus area based on high malnutrition rates, leveraging data from the National Family Health Survey (NFHS-5), and exploring alternative proteins for sustainable, local, and culturally appropriate nutrition solutions. Results include recommendations for enhancing the Public Distribution System (PDS) by incorporating legumes into meals and fortifying foods with legume powders, alongside suggestions for supporting local farmers and integrating educational programs. This multifaceted approach seeks to reduce malnutrition, improve health outcomes, and promote sustainable food practices in Bihar.

Personal Motivations

Throughout my life, I have been passionate about the social aspect and the idea of helping others to positively impact their lives. At the same time, I have also been drawn to engineering, processes, and project management. This project has been the perfect opportunity to combine both interests. It aims to improve the quality of life for children by addressing malnutrition during a critical stage of their development, thus laying the foundation for a healthier and more promising future. I am deeply motivated to contribute to building a better future from the start, ensuring that these children receive adequate and sustainable nutrition that positively influences their growth and development.

Context of the Malnutrition Problem

Despite its remarkable economic growth over the past two decades, India continues to face alarming levels of hunger and acute malnutrition. India, the world's second most populous country after China, with 1.21 billion inhabitants, has seen an absolute increase of 181 million in its child population between 2001 and 2011 (Sukanya Chakravorty, 2023). According to a World Bank report from 2021, approximately 15% of India's population, or 150 million people, suffered from moderate to severe undernourishment (World Bank, 2021). UNICEF estimates that three out of every ten malnourished children globally live in India (UNICEF, 2019), where malnutrition arises from deficiencies in energy, proteins, vitamins, and essential minerals due to inadequate food intake.

The objective of this project is to utilize a variety of plant-based and alternative protein products to address high levels of malnutrition in a specific region of India, where alarming malnutrition rates among children under five years old have been observed according to official data. These products have been chosen for their ability to promote environmental sustainability, efficient production costs, use of locally available raw materials, commitment to animal welfare, as well as for promoting sustainable agricultural practices and improving food security in the region.

Despite initiatives implemented by the Indian government in collaboration with the private sector and international organizations such as UNICEF, Seed for Change, World Bank, ActionAid India, and Seva Mandir, such as the National Food Security Act, the Poshan Mission, and the National Nutrition Strategy, significant challenges persist that require innovative and sustainable solutions like this one.

One of these efforts is the Public Distribution System (PDS), an entity under the Ministry of Consumer Affairs, Food, and Public Distribution. The PDS originated from the rationing system introduced by the British during World War II to provide basic food supplies to urban centers and some rural areas suffering from chronic food shortages. In 2016, the Indian government allocated approximately $20.743 billion to the PDS (Navarrete, 2017).

Continued efforts and multisectoral approaches are essential to achieving sustainable development goals and ensuring everyone's right to adequate nutrition. Child malnutrition in India claims the lives of 69% of children under five years old (UNICEF, 2019) and causes irreparable physical harm, hindering proper brain development and increasing the risk of nutrition-related chronic diseases (Partha, 2021).

In India, 36% of children under five years old suffer from stunted growth (too short for their age), indicating chronic malnutrition. Nineteen percent of children under five suffer from acute malnutrition, characterized by thinness (too thin for their height), while 32% have low weight for their age. Three percent of children are overweight (National Family Health Survey, NFHS-5, 2022).

Levels of malnutrition vary significantly across the country, depending on factors such as socioeconomic levels and regions. According to data from the National Family Health Survey (NFHS-5) of 2019-2020, the prevalence of chronic malnutrition (low weight for age) among children under five in Bihar is 43.9% (Ministry of Health and Family Welfare, 2020).

Chronic and acute malnutrition differ in their origins, development time, and consequences. Chronic malnutrition, resulting from inadequate nutrient intake over time, leads to stunted growth and a weakened immune system. Acute malnutrition, caused by recent illness or lack of food, results in weight loss, dehydration, and a high risk of mortality if not promptly treated. Therefore, this project focuses on addressing acute malnutrition, as it presents a window of opportunity for rapid and effective recovery. Its lesser complexity facilitates identifying causes and implementing specific measures. Focusing on this condition helps direct efforts towards saving lives and significantly improving the health and cognitive development of the most vulnerable children, leading to better quality of life throughout their lives.

Emerging economies like Thailand (Garg & Nandi, n.d.) have shown that child malnutrition can be drastically reduced, halving the percentage of underweight children from 50% to 25% between 1980 and 1986 through educational campaigns on the importance of balanced diets, improved access to basic health services, and strengthened food security. International collaboration and support from donor organizations also played a crucial role in this success, demonstrating that effective policies and well-designed programs can significantly combat child malnutrition.

Similarly, Brazil reduced child malnutrition by 75% (from 20% to 5%) between 1990 and 2006 (Saxena, 2012) through the expansion of school feeding and child nutrition programs, such as the National School Feeding Program (PNAE), which ensures nutritious meals for students. Primary health care programs were also strengthened, improving access to medical and nutritional services for low-income children and families. Other key measures included promoting exclusive breastfeeding and nutritional education campaigns to raise awareness about healthy eating practices.

These international examples demonstrate that with effective policies and collaboration across multiple sectors, it is possible to combat malnutrition and improve the health of millions of children in India. Effective policies are crucial in combating child malnutrition because they address the underlying causes of this complex problem. These policies can include school nutrition programs, vaccination campaigns, maternal and child health services, and the provision of nutritional supplements. By implementing these strategies, governments can ensure that children receive essential nutrients for their growth and development. Additionally, policies can promote sustainable agricultural practices and improve food security, which also contributes to reducing malnutrition.

The government's role is crucial in the fight against malnutrition in India. The government has the capacity to formulate and implement national policies that reach the most vulnerable populations. It can coordinate efforts across various sectors, including health, education, and agriculture, to create a comprehensive and multifaceted approach. Furthermore, the government can mobilize financial and technical resources, establish regulations and quality standards, and monitor and evaluate programs to ensure their effectiveness. Collaboration with non-governmental organizations, international agencies, and the private sector is also essential to amplify the impact of these policies and ensure successful implementation.

Methodology

The project aims to address child malnutrition in Bihar, India, by focusing on four regions identified from NFHS-5 data as having the worst indicators, such as high rates of stunting and wasting. We utilized an online course from JPAL, "Impact Evaluation of Social Programs" by MIT Online, to guide our research methodology and planning. This course provided valuable insights into evaluating social programs effectively and ensuring our approach was evidence-based.

Additionally, we referred to Geever's "Guide to Proposal Writing, Third Edition" to understand what information is required to secure funding and the common questions funders typically ask. Our strategy involves analyzing NFHS-5 data, developing a nutrition program that includes community dining initiatives and legume-based food fortification, and then implementing and monitoring this program in the targeted regions. The goal is to improve child nutrition and overall well-being through these tailored interventions.

Results and Discussion 

Choosing the Estate

There are various indicators to assess malnutrition at the state level in India. Some of the most common ones include:

• India State Hunger Index (ISHI): Developed by the International Food Policy Research Institute (IFPRI), this tool measures hunger and malnutrition at a regional level. It provides scores for 17 Indian states, representing over 95% of the population. ISHI considers four indicators:

  1. Rate of child wasting (under five years)

  2. Rate of child stunting (under five years)

  3. Infant mortality rate

  4. Percentage of population with inadequate food consumption

• Prevalence of malnutrition: This indicator reflects the percentage of the population suffering from some form of malnutrition, such as stunting, wasting, or underweight. It is derived from national surveys like the National Family Health Survey (NFHS).

• Mortality rate due to malnutrition: This indicator measures the number of deaths attributable to malnutrition per 1,000 people.

For the purposes of this project, the National Family Health Survey (NFHS) will be chosen as the measurement indicator to help select the state for intervention. This survey is a national-level survey that provides a robust and reliable database with information broken down by age, sex, socioeconomic status, and geographic location, allowing for the identification of disparities and the most vulnerable population groups. Its rigorous methodology, wide range of indicators, regular periodicity, and detailed data breakdown enable a precise assessment of malnutrition in the country, making it a crucial tool for formulating health and nutrition policies and programs.

Up to now, five rounds of the National Family Health Survey (NFHS) have been conducted in India. These rounds occurred in the years 1992-1993 (NFHS-1), 1998-1999 (NFHS-2), 2005-2006 (NFHS-3), 2015-2016 (NFHS-4), and 2019-2021 (NFHS-5) (Ministry of Health and Family Welfare, 2020). Each round provides updated data on various aspects of health and nutrition in India, allowing for monitoring trends over time and evaluating the impact of public health policies and programs. Data collection is currently underway for the 2023-2026 period (NFHS-6), and official data has not yet been published. Therefore, we will focus on the available official public data, specifically from NFHS-5.

To choose the state for study, we rely on the most recent data available up to the NFHS-5 survey in India. In order to make a meaningful comparison, we select regions where the percentage of child malnutrition, specifically stunting, exceeds 40%. This threshold is associated with quality of life, proper introduction of complementary foods, sanitary and hygiene conditions, as well as socioeconomic conditions such as household income and food security, among other quality of life factors.

The impact of child malnutrition can be measured in terms of years of life lost. For each criterion, we assign a weighted percentage, with each subcategory receiving an allocated percentage. The prevalence of child malnutrition is considered primary due to its direct connection to years of life lost. Secondly, infant feeding practices are evaluated. This aspect is particularly relevant for my project, which focuses on promoting plant-based diets and alternative protein sources in these vulnerable populations.

Now that we have the criteria and their respective weights based on their importance and relevance to this project, it's time to assign percentages and weights to each sub-criterion. The total sum of these should always be 100%.

Table 3. Weighted Factors Matrix. CONSIDERATION: A higher score indicates a greater negative impact on malnutrition scenarios, making the region a comparative priority over others.

Based on the results of the prioritization matrix and the assigned scores, we have determined that we will focus on the state of Bihar, as it obtained a total score of 38.4, the highest among all evaluated states. The calculations are verified, as both the horizontal and vertical sums total 100%.

Selecting the target group

Malnutrition encompasses deficiencies and excesses in nutrient intake, as well as imbalances in essential nutrient utilization by the body, manifesting in forms such as wasting, stunting, low weight, and micronutrient deficiencies. These conditions are especially critical in children under 5 years old, increasing the risk of infant mortality and limiting physical and cognitive development. To address these challenges, this project will focus on children who are already consuming solid foods after six months, when breast milk alone is no longer sufficient.

After six months, it is crucial to introduce appropriate complementary foods that include a variety of essential nutrients, such as fruits and vegetables rich in vitamin A, as indicated by the NFHS-5 survey (2019-2021). We will concentrate on addressing micronutrient deficiencies and stunting, critical aspects that affect both individual child development and national public health. It is essential to prevent the long-term devastating effects of early childhood malnutrition through effective and timely interventions, leveraging the opportunity provided by the early years of life for healthy and sustainable development.

Early intervention is crucial as it helps prevent serious health problems and improves long-term prognosis. This strategy focuses on seizing the window of opportunity offered by the early years of life to ensure healthy development and avoid negative consequences that could affect children's overall well-being and future potential. In summary, the combination of the rapid response of the infant body and timely interventions makes acute malnutrition in children more treatable and less likely to cause severe long-term effects compared to adults.

Role of alternative proteins and plant-based diets in the fight against malnutrition

Alternative proteins and plant-based diets offer a range of significant benefits in the fight against malnutrition, especially in countries with limited resources or unsustainable meat production systems. These options are often more cost-effective and accessible, improving protein intake, especially among vulnerable populations. Furthermore, they can enhance nutritional profiles by being rich in nutrients and low in saturated fats, thereby helping to reduce the risk of chronic diseases.

From an environmental standpoint, alternative proteins have a reduced impact compared to meat production, making them a more sustainable option for feeding a growing population. They also offer advantages in food security by being more resilient to adverse conditions and requiring fewer resources for production, thereby freeing up resources for other food crops.

While promising, it's important to recognize that alternative proteins are not a singular solution to malnutrition. Ensuring their nutritional completeness and cultural appropriateness is necessary, as well as implementing effective education and promotion strategies for adoption. Investment in research and development is also crucial to improve the quality and taste of these alternatives. In summary, successful implementation requires a comprehensive approach that addresses various social, economic, cultural, and public health aspects.

The information obtained from the NFHS-5 report on the foods consumed by children under two years old is useful for assessing whether they are ingesting sufficient foods containing two fundamental micronutrients: vitamin A and iron. Iron deficiency is one of the leading causes of anemia, which has serious health implications for both women and children. Vitamin A is crucial for the immune system and maintaining the integrity of epithelial tissue in the body. Severe vitamin A deficiency can lead to eye damage and is the leading cause of childhood blindness. Moreover, it increases the severity of diseases such as measles and diarrheal diseases in children, delaying recovery. This deficiency is common in dry areas where there is limited access to fresh fruits and vegetables (NFHS-5, 2019-2021).

Selecting the product family or product

The market for plant-based products in India is experiencing significant growth, driven by increasing consumer interest in healthier, sustainable, and ethical options. It is projected that this market will reach $450 million in the next five years, with product categories such as plant-based milk, yogurt, cheese, meat, and burgers gaining popularity (enAlimentos, 2022). This growth is attributed to greater awareness of the health benefits, animal welfare considerations, and environmental sustainability of plant-based diets.

Despite the rapid growth, the plant-based products market in India is relatively new and fragmented, with numerous small and medium-sized enterprises competing for market share. However, standout companies such as GoodDot, Plant Veda, Soypunk, Mumbai Masala, and The Green Protein are leading innovation in this sector, offering a wide range of plant-based products that meet the demands of the expanding market.

As more companies join this trend and introduce new options to the market, the landscape of plant-based products in India is expected to continue expanding to offer more delicious and nutritious alternatives to consumers. Despite challenges such as lack of awareness, limited accessibility, and cultural taste preferences, ongoing efforts in education, product development, and promotion could pave the way for greater adoption of plant-based diets in India, offering significant health, environmental, and economic benefits for the country.

As part of this adaptation, manufacturers are collaborating with chefs and food experts to develop products that are not only nutritious and sustainable but also appealing to the palates of local consumers, thus facilitating a transition to more balanced and environmentally-friendly diets in India.

Its cultivation can also be more sustainable in terms of water resource usage and agricultural management, which is crucial in a region like Bihar where resource management is key to long-term food security.

In terms of water consumption in food production, meat products such as beef use a significantly high amount of water resources, with approximately 15,415 liters needed to produce one kilogram, according to data from the study by Mekonnen and Hoekstra (Water Footprint Network, n.d.). This amount positions beef as the least sustainable in terms of water usage among meat types. In contrast, vegetables require considerably less water, around 322 liters per 1000 grams, making them a more water-efficient option.

Recommendations 

Considering the context in which this project is unfolding in India, a diverse nation with over 1.4 billion inhabitants facing significant challenges such as emerging technological development and persistent inequality and poverty, we are witnessing a revolution in food towards plant-based diets. This transformation is driven by growing awareness of health and environmental benefits.

India, as a key player in this transition towards more sustainable nutrition, is not immune to this trend. Therefore, the following recommendations seek to bridge these two worlds to address a specific issue in a crucial region like Bihar. We have chosen Bihar due to its high impact on malnutrition levels, especially among children under five years old after exclusive breastfeeding. Leveraging this early developmental window is crucial to ensuring healthy growth and preventing long-term adverse consequences.

In this context, we have decided to focus on implementing plant-based products, such as legumes (lentils, chickpeas, beans), due to their prominent local availability, nutritional value, and agricultural sustainability.

We propose two strategies:

• Nutritional Community Dining Program

The Public Distribution System (PDS) in India subsidizes staple foods like rice, wheat, and sugar. A crucial recommendation is for the PDS to expand its distribution to institutions already identified with populations suffering from acute malnutrition. For example, Intensive Care Units for Malnourished Children (MICUs) offering specialized and high-complexity care to children with malnutrition, AIIMS Patna hospital with a pediatrics department specialized in severe acute malnutrition, and childcare centers like Ashiana Children's Home in Patna equipped with Malnutrition Treatment Units (OTNs). It is recommended to incorporate at least ½ cup of legumes in each meal, ideally once or twice daily continuously and supervised, making adjustments as necessary to maximize nutritional and health benefits.

• Food Fortification with Legumes through the PDS

Fortify soups, porridges, and cereals with a fine powder made from lentils, chickpeas, and beans, ensuring they are fully cooked and ground for easy digestion and nutrient absorption. This process significantly increases the content of proteins, fiber, and essential vitamins, maintaining uniformity without compromising the taste or texture of the final product.

Additional Recommendations

• These recommendations may be more effective when combined with other interventions, such as nutritional education programs and health services. It is crucial to monitor and evaluate implemented programs to ensure their effectiveness and efficiency. This includes ensuring that we are targeting the appropriate population and addressing key questions, such as whether the portion size is adequate or needs adjustment, whether partnerships and collaborations are right to truly benefit the affected population, and whether the impact is meeting expectations or if other sources of proteins and vitamins need consideration, among other aspects.

• Supporting farmers in Bihar in adopting sustainable agricultural practices to improve the production and quality of legumes is essential. This may include providing training in agroecological farming techniques, facilitating access to high-quality legume seeds, and offering financial assistance to establish suitable agricultural infrastructure.
 

Research Conclusions

The project focuses on addressing the high prevalence of child malnutrition in Bihar, selected due to concerning levels of stunting and underweight among children under five years old. Child malnutrition not only impacts the physical and cognitive development of children but also has long-term implications for public health and the regional economy. Therefore, implementing effective interventions to improve the quality of life and developmental potential of future generations in this region is crucial.

The central strategy of the project is the promotion of legumes to combat acute malnutrition. These options are culturally accepted, economically accessible, and have a lower environmental impact compared to animal-based alternatives. Furthermore, these diets have been observed to effectively improve the intake of essential nutrients among affected children, which can facilitate quicker and sustainable long-term recovery.

To ensure the project's success, collaboration among the government, local non-governmental organizations, and the private sector is essential. Together, these stakeholders can implement appropriate policies and well-designed programs that not only promote the adoption of healthy diets but also strengthen local infrastructure and improve socio-economic conditions contributing to child malnutrition. With a comprehensive and sustainable approach, the project aims to significantly reduce child malnutrition in Bihar and lay the foundation for healthy and equitable development in the region.

While legumes represent a promising alternative to combat child malnutrition, it is important to recognize that they do not constitute a singular solution. A comprehensive approach is required that encompasses nutritional supplementation, culturally appropriate education, implementation of national and regional policies, and effective advocacy to achieve lasting and significant impact.

Personal Conclusions

This project was my first attempt at creating a social program, and it was a real learning experience. I discovered that making a positive impact is quite challenging; it requires a lot of creativity to find the best ways to reach people and create significant change. The course on impact evaluation from JPAL was invaluable, offering practical insights into designing and assessing social programs. It highlighted the importance of understanding how to measure success and adapt strategies to be more effective.

I also learned that successful social programs need a broad approach involving various sectors. From the course and our research, it became clear that collaboration between government, private sector, and local organizations is crucial. These different groups need to work together, combining their resources and expertise to ensure the program is well-designed and achieves its goals. It would be an honor to bring this project to life, whether in Bihar or any other part of the world, and contribute to making a meaningful difference in people’s lives.

References

Banco Mundial. (2021). Prevalencia de desnutrición (% de la población) - India. Obtenido de https://datos.bancomundial.org/indicator/SN.ITK.DEFC.ZS?locations=IN

enAlimentos. (09 de Junio de 2022). Obtenido de https://enalimentos.lat/noticias/5472-se-preve-que-mercado-indio-de-productos-plant-based-alcance-los-450-mdd-en-los-proximos-cinco-anos.html

Ministry of Health and Family Welfare. (20 de December de 2020). National Family Health Survey-5. Obtenido de https://pib.gov.in/Pressreleaseshare.aspx?PRID=1680702#:~:text=Four%20rounds%20of%20NFHS%20(1992,as%20the%20national%20nodal%20agency.

National Family Health Survey, NFHS-5. (March de 2022). Obtenido de https://dhsprogram.com/pubs/pdf/FR375/FR375.pdf

Navarrete, A. G. (30 de Junio de 2017). La cuestión cuestion alimentaria en India: Papel del sistema publico de distribucion de alimentos. Obtenido de https://www.uv.es/edhc/edhc007_gimenez.pdf

NFHS-5. (September de 2019-2021). Obtenido de National Family Health Survey: https://ruralindiaonline.org/hi/library/resource/national-family-health-survey-nfhs-5-2019-21-uttar-pradesh/#:~:text=NFHS%2D5%20presents%20district%2Dlevel,presents%20information%20covering%2075%20districts.

Partha, A. (16 de Marzo de 2021). Desnutrición infantil en la India – un problema que necesita erradicación. Obtenido de https://www.humanium.org/es/desnutricion-infantil-en-la-india-un-problema-que-necesita-erradicacion/

ReporteAsia. (21 de February de 2023). Cómo puede la India ser autosuficiente en legumbres. Obtenido de https://reporteasia.com/opinion/2023/02/21/como-puede-india-ser-autosuficiente-legumbres/

Saxena, N. (July de 2012). Hunger and Malnutrition in India. Obtenido de https://www.researchgate.net/publication/264211667_Hunger_and_Malnutrition_in_India

Semilla para el Cambio. (20 de Noviembre de 2021). India es uno de los peores países para garantizar el derecho de los niños a una alimentación saludable. Obtenido de https://www.semillaparaelcambio.org/2021/11/india-es-uno-de-los-peores-paises-para-garantizar-el-derecho-de-los-ninos-a-una-alimentacion-saludable/

Sukanya Chakravorty, M. (02 de June de 2023). Data analysis of malnutrition in India: a review of numerous factors. Obtenido de https://www.ijcmph.com/index.php/ijcmph/article/view/11098/6799

The World Bank and Nutrition. (29 de June de 2023). Obtenido de World Bank Group: https://www.worldbank.org/en/topic/nutrition/overview

UNICEF. (Octubre de 2019). Niños, alimentos y nutricion. Obtenido de https://www.unicef.org/sites/default/files/2019-11/Estado-mundial-de-la-infancia-2019.pdf

Water footprint Network. (s.f.). Do you know how much water was used to grow your food and to produce your clothes and the things you buy? Obtenido de https://www.waterfootprint.org/time-for-action/what-can-consumers-do/

World Health Organization. (s.f.). Malnutrition. Obtenido de https://www.who.int/health-topics/malnutrition#tab=tab_1