The cereal monopoly: A recipe for undernutrition

After every visit to the Public Distribution System (PDS) outlet, Shantamma sits on her porch in a village in Chikkaballapur, Karnataka, picking out husk, rocks and other impurities. The slightly discoloured grains of rice she is throwing away are fortified with nutrients, but she does not know this.

In an effort to counter malnutrition, the Union government introduced rice fortified with iron, folic acid and vitamin B-12 in the country.

Like Shantamma, many in her village are in the dark about the rice that they are eating. They are unaware of the controversy surrounding fortification and the dangers it could pose to people with certain illnesses.

With a monthly income of Rs 9,000 and a family of four to care for, Shantamma acknowledges that the PDS provides rice and ragi, but it is not enough. “Can we go to sleep with just rice in our stomachs? We need to spend money on vegetables, oil, sugar and pulses,” she says.

Close to 71 per cent of India cannot afford healthy meals, according to a 2022 report by the Food and Agriculture Organisation (FAO). A diet becomes unaffordable when it costs more than 63 per cent of a person’s income. India fares worse than countries like China (12 per cent) and Brazil (19 per cent).

A study by the Centre for Science and Environment found that 1.7 million in India die every year due to diseases caused by a poor diet. These figures only show that the country’s food programmes need to begin addressing nutrition insecurity, rather than singularly focusing on food security.

Mallikarjun, an agricultural labourer in Chikkaballapur, says that the recent rise in food prices means that his family shops for vegetables and meat fewer times in the week. Fruits are out of the question. “With no land to cultivate vegetables, we are forced to buy what we cannot afford. We have just started eating less vegetables,” he says.

About 60 per cent of Indians receive foodgrains through the PDS — a majority of states are supplied with rice and wheat. While the cereal-heavy programme might meet caloric requirements, it masks serious nutritional deficiencies.

The green revolution increased the country’s dependence on cereal. Overcultivation of cash crops, and the decline of millets, has contributed to the crisis. There is a need to diversify food crops immediately.

This is evident in the nutritional status of ration cardholders, who score poorly across all indicators. A 2019 study by a private consulting firm assessed the nutritional gaps in households that consumed foodgrains received through the PDS.

The study revealed that all beneficiaries – men, women, pregnant and lactating women and children – had low levels of basic macro and micronutrients. This included serious deficiencies in protein, fat, calcium, iron and folic acid.

The study expounds that only 18 per cent and 20 per cent of the protein needs of men and women were met through government programmes. Pregnant women, lactating mothers and children, who avail nutritional supplements through the Integrated Child Development Services (ICDS), fared comparatively better. However, at least 50 per cent of their protein needs still went unmet.

Why do these programmes fail to address nutritional insecurity? The problem, experts say, is with the lack of dietary diversity.

Monotonous diets

“We are only providing people with cereal. The body needs more than just carbohydrates – it needs pulses, legumes, eggs, oil and meat. It needs variety,” says Dr Veena Shatrugna, former deputy director of the National Institute of Nutrition, Hyderabad. There are more than 20 micronutrients that the body needs, she explains.

Most micronutrients are available naturally in legumes, greens, fruits, dairy, egg, meat products and oils, which remain out of reach for many deprived communities.

“Though the PDS comes under the justiciable right to food, many people, including the government, view it as a charity initiative. They think something is better than nothing,” says Dr Vandana Prasad, a Delhi-based community paediatrician and a public health expert.

It is natural to crave variety, experts say. To satiate this craving, many people have come to depend on biscuits, chips and other ultra-processed foods. “My child cries if I don’t give him something with his rice, so I end up buying biscuits or chips to go along with his food,” says Geetha (name changed), a construction worker in Bengaluru.

An excess of these easily available snacks with a cereal-heavy diet can cause obesity and trigger non-communicable diseases like diabetes and hypertension. India already suffers from a diabetic problem of epic proportions with 74.2 million afflicted with the disease. It is only surpassed by China.

Cereal-heavy diets can also hide malnutrition and keep people from seeking out treatment. “Several studies establish that the effects of undernutrition are severe, affecting thinking, intelligence, cognition and daily activities,” says Dr Prashant N S, assistant director at the Institute of Public Health, Bengaluru.

According to the World Bank, India loses up to US $12 billion annually due to vitamin and mineral deficiencies.

Rice fortification

The latest ‘silver bullet’ to tackle anaemia caused by malnutrition is rice fortification. In his Independence Day address last year, Prime Minister Narendra Modi announced that rice supplied under all schemes would be fortified by 2024.

The move was not received well by experts, doctors and nutritionists, who have called into question the evidence, effectiveness and ethics behind the decision.

Evidence to support the effectiveness of fortification in tackling anaemia is nebulous. An RTI query submitted to the Indian Council of Medical Research – National Institute of Nutrition (ICMR-NIN) found that both fortified rice and regular rice in midday meals had a similar effect on the reduction of anaemia.

Contemporary research also calls into question the high stipulation of iron requirements in the past. “The daily requirement for iron as a nutrient was thought to be very high (before 2020). One could not possibly meet this through a normal diet. Such a situation brings up the need for fortifying the diet,” says Dr Anura Kurpad, professor of physiology and nutrition at St John’s Medical College, Bengaluru. In 2020, new research revealed that a regular, diverse diet could sufficiently meet iron requirements.

Focus on individual

For those who do suffer from vitamin and mineral deficiencies, a clinical approach is vital. The PDS, which is designed to count households as units, and not individuals, is insufficient to address malnutrition. “A case management approach is the right way to address nutritional deficiencies. A clinical intervention, with doctors who can monitor and stop dosages, is safe,” says Kavitha Kuruganti, of the Alliance for Sustainable and Holistic Agriculture (ASHA), who was part of a recent fact-finding visit to Jharkhand on rice fortification.

The fact-finding report observed that fortified rice could be dangerous for people who suffer from thalassemia, sickle cell anaemia, malaria, tuberculosis and even those with severe acute malnutrition. Even people who have the genetic trait and not the clinical disease could absorb an excess of iron and be at risk.

Kapil Mohan, Additional Chief Secretary of Food and Civil Supplies, Karnataka, explains, “This is only a miniscule amount of the population. The programme will benefit the majority.”

It is unclear if those with thalassemia and sickle cell anaemia were informed when they were provided with fortified rice. There is also uncertainty whether alternative options will be made available to them at PDS centres.

In conversation with DH, a PDS dealer, on the condition of anonymity, said that there were no information campaigns about fortified rice in Chikkaballapur. “Vendors like me attended an informational session conducted by the District Commissioner. I only explain to consumers when they ask me about the fortification process,” he says. A vast majority does not ask.

A lack of effort to raise awareness is a grave violation of citizens' rights to make informed choices. “Citizens should have the first say in what they consume. Their food choices should not be dictated. The government must take a collaborative approach,” says Dr Prasad.

Unscientific approach

There is also a tendency to attach a notion of ‘impurity’ towards meat-eating. “There is a push towards vegetarianism that is proving discriminatory towards minority, tribal and scheduled caste communities. For instance, traditionally, many marginalised communities consumed beef which is a cheap and nutritious source of protein and iron,” says Dr Prasad. However, restrictions on beef consumption exist in 20 out of 28 states.

Meat products have high biological value, since they are rich in protein, iron, vitamin B-12, zinc, selenium and phosphorus. Nutritionists have long advocated for the inclusion of eggs in midday meals due to their high protein, vitamin and mineral content.

A parent in Bengaluru who receives eggs for her five-year-old daughter through ICDS says, "My daughter goes to the anganwadi for the eggs. She can eat anything with eggs,” she says. Yet, in a country with a meat-eating population of 70 per cent, only 13 states and 3 union territories provide eggs in midday meals.

Even Karnataka, which started providing eggs in seven districts recently, came out with a National Education Policy position paper that suggests a ban on eggs and meat in midday meals. It claims they lead to ‘lifestyle disorders’.

Attaching morality to food and nutrition can be extremely detrimental. “People are free to use religion as a justification for their own food choices but not to thrust it upon others,” says Dr Prasad.

Way forward

“Food cultures have evolved over long periods. Kitchens were once nutritionally rich places because of the many different varieties of grains, meat, vegetables and fruit,” says Kuruganti.

Cultivating a holistic diet is inextricable from agricultural diversity. Local food crops, such as millets, have retreated from farms following the green revolution. The lack of crop variety, owing to the rapid expansion of commercial and cash crops, has contributed to poor diets.

“A serious effort needs to be made to diversify India’s food basket, and to protect farmers who grow diverse foods, rather than just cereals,” concludes Dr Kurpad.

Without sufficient evidence and stakeholder involvement, the fortified rice project becomes a one-size-fits-all solution. This ignores cultural diversity and nutritional requirements.

A sound way forward is to adopt a collaborative, decentralised approach. There is a need to empower citizens to make informed choices. Communities have a right to access and consume diverse foods through a public distribution system that makes this possible.