New Delhi: Cutting across the wealth divide, more than a quarter of Indian children under two years of age who were surveyed for a new study did not eat a diversified diet. More than household wealth, it was the mother’s education that influenced how well toddlers and infants ate, the study has concluded.

Only 23% of children aged 6-23 months received an adequately diversified diet, according to the study by Sutapa Agarwal from Tata Trusts, Rockli Kim and S V Subramanium from the Harvard Center for Population and Development Studies of Harvard University, and others, published in the European Journal of Clinical Nutrition in February 2019.

Among the poorest households, 18% of children had a sufficiently varied diet as compared to 28% of children from the richest households, a difference of 10 percentage points. At the same time, 17% of children of mothers with no education ate an adequately diversified diet as compared to 30% of mothers with a high school or higher education, a difference of 13 percentage points, the study found.

An “adequately diversified diet” entailed consuming at least four items from seven food groups used for the purpose of the study--grains, roots and tubers, legumes and nuts, dairy products, flesh foods (meat), vitamin A-rich fruits and vegetables, and other fruits and vegetables.

Eating a varied diet is as important, if not more, than the quantity and quality of nutrition. In the study, most children had a higher consumption of grains and a poor consumption of fruits and vegetables, nuts and legumes, eggs and meat.

“More than animal versus plant--we need to think of macro nutrients related to the balance between fat, protein and carbohydrates,” said Subramaniam, one of the co-authors of the study, in an email. “And for young children fat intake is critical. There is an emerging recognition to focus on proteins, but not nearly enough for fat intake among very young children. And here is where dairy consumption--including milk--is important for addressing the burden of child undernutrition.”

Wealth and education gap

“For the poorer strata it is affordability and accessibility, while for the better-off strata it could be lack of knowledge,” said Subramaniam, explaining the study’s findings. Food is an industry now, he said, adding that dietary preferences among the well off need to be interpreted in the larger context of global trends towards homogenous food.

Home to almost a third of the world’s stunted children under five (46.6 million), India is not on track to reach the World Health Organization’s 2025 global nutrition targets, IndiaSpend reported in January 2019.

Of Indian children under two years of age, 90.4% did not receive an adequate diet, the National Family Health Survey-4 (NFHS-4) 2015-16 found. Some 18% of children aged 6-23 months ate iron-rich foods, and more than half the children in this age group were anaemic. About 54% consumed vitamin A-rich foods, the lack of which can lead to childhood blindness and poor immunity.

The present study on dietary diversity also used NFHS-4 data, in which mothers were asked to choose from a list of 21 food items they had given their children in the preceding 24 hours.

The items were then divided into seven food groups: grains, roots and tubers, legumes and nuts, dairy products, flesh foods, vitamin A-rich fruits and vegetables, and other fruits and vegetables.

The mean score of dietary diversity of Indian children was found to be 2.26, on a 0-7 scale, where 0 means children are not fed any of the 21 food items and 7 means they are fed at least one from all seven groups.

The biggest difference between children of different wealth groups was in consumption of dairy products--children in the richest households were three times more likely to consume dairy products as the poorest households.

Meanwhile, children of mothers with high school or higher education had a greater likelihood of consuming all seven food groups and had twice the odds of eating an adequately diversified diet as those with mothers with no education.

Grains consumed most

Among the seven food groups, children mostly ate grain--74% were reported to have consumed roots and tubers, 55% dairy products, 37% other fruits and vegetables, and 29% vitamin A-rich fruits and vegetables.

Children’s consumption was the lowest for eggs (14% of respondents), legumes and nuts (13%), and flesh foods (10%), the study found.

Between the richest and poorest households, the difference in consumption of dairy products was the highest (39% in poorest households vs 72% in richest households), followed by vitamin A-rich fruits and vegetables (26% vs 33%) and other fruits and vegetables (34% vs 40%).

Consumption of dairy products varied most by mothers’ education level--44% for uneducated vs 73% for educated--followed by vitamin A-rich fruits and vegetables (25% vs 34%), and other fruits and vegetables (32% vs 43%).

Although dietary diversity increased in 2016 as compared to 2006, it was poor throughout and actually reduced in the upper two wealth groups (out of five). Despite the reduced gap, the upper groups consumed 2-4 times more diversified diets than those in lower groups.

Consumption of some food items was influenced more by maternal education than household wealth. These included: pumpkin, carrots, squash, dark green leafy vegetables, liver, heart, organ meat, fish, shellfish, legumes and nuts, and flesh food.

Consumption of packaged items such as canned juices increased with increased wealth and mother’s education, which the researchers called “alarming”. They suggested that food items that are cheap in India such as pumpkin, carrots and dark green leafy vegetables should be encouraged.

Can more meat help?

To improve dietary diversity, children should be eating more animal-sourced foods. Indians consumed 194 gm and 242 gm of protein a day in rural and urban areas, respectively, against the recommended 459 gm, according to an analysis published in Livemint in January 2019.

Although dairy and poultry foods are cheaper in India than in some low- and middle-income countries, they remain beyond the reach of many. Here, cash transfers can play a role, said a study on child feeding practices in 2006 and 2016 conducted by the agriculture research group International Food Policy Research Institute (IFPRI) and published in the journal Maternal and Child Nutrition.

It would also be important to remove cultural barriers to meat consumption among young children, the study said. Among the one-third households that did not consume animal protein, improving consumption of legumes/nuts and fruit and vegetables could help, said Phuong Nguyen, a co-author of the IFPRI study, on email.

Another study from IFPRI had found that despite health and nutrition education increasing three-fold from 3.2% in 2006 to 21% in 2016, the poorest mothers had the second worst coverage of health and nutrition services (after the richest group), IndiaSpend reported in March 2019.

(Yadavar is a principal correspondent with IndiaSpend.)

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Swagata Yadavar

    Swagata Yadavar is an award-winning independent journalist based in New Delhi. She writes on public policy, healthcare and gender related themes. Previously, she worked with ThePrint, IndiaSpend and The Week. Her bylines appear in Cancer World, Al Jazeera, Business Insider, Article 14, Scroll, Behenbox among others.