Long before the pandemic, evidence showed a persistent deficiency in food intake of women in India. A convergence of policies and programs across sectors can boost the nutrition security of women and their communities.
Why a diverse diet is important
Diet-related malnutrition affects one out of three individuals globally. Poor quality diets are now the predominant risk factor behind the global burden of disease. Not only are healthy diets important for individual well-being but they have implications for intergenerational health as well. Maternal dietary diversity has been associated with significantly lower rates of malnutrition in children across countries. When diets are lacking in the recommended amounts of a diverse set of foods, countries and communities are faced with the ‘double burden’ of malnutrition wherein undernutrition coexists with over-nutrition. Globally nearly 900 million people worldwide are hungry and undernourished even as more than a third of the adult population is overweight or obese.
Over the last five years the Tata-Cornell Institute for Agriculture and Nutrition at Cornell University has been leading a program to design and implement nutrition-sensitive food systems in India. Evidence from its on-the-ground interventions and time series surveys points towards a persistent deficiency in food intake of women. This is driven by the increasing unaffordability of healthy diets in the country and compounded by an unequal distribution of food within the household. Both the affordability and parity of dietary intake has been worsened with the onset of the COVID-19 pandemic.
What we know about dietary diversity
TCI’s evidence base on dietary intake from rural India indicates that women’s diets are cereal- centric, being heavily centered around staples like rice and wheat. At the same time their consumption of nutrient-dense non-staple foods is significantly lower. Fewer than three in every ten women consumed iron-rich green leafy vegetables, Vitamin-A rich fruits, and meats and dairy products that are rich sources of proteins. Furthermore, nearly two thirds of women had below- average dietary diversity scores.
Recent data suggest that women’s diets are adversely affected by both intrahousehold food allocation decisions and exogenous shocks to the household. On average, women’s diets are less diverse than that of the rest of their household in rural India. In other words, there are some food groups that are being consumed in the household—but not by the woman herself. Such a divergence in the diet diversity of women as compared to their households is especially visible for food groups like meats, dairy, green leafy vegetables and Vitamin-A rich foods. In nearly 20 percent of the households where these foods were being consumed, the woman did not consume them. Given that the overall consumption of these foods—even at the household level—is very low, this points to the urgency of addressing such persistent gaps in diet diversity of women through a gendered lens.
It is now agreed that the COVID-19 pandemic has severely affected food and nutrition security, with the impact being disproportionately large for women and children. Our analysis of data on food consumption and household expenditures before and after the pandemic onset in India indicates that there was a significant decline in the dietary diversity of women in rural India, particularly for fruits and vegetables. At the same time households reduced their spending on foods like fruits, vegetables, meat and eggs. We conclude that while the expansion of food safety nets continued to provide cereals like rice and wheat, households’ access to local food markets for non-cereals was disrupted following the nationwide lockdown. Furthermore, the disruption in food supply chains meant that, at least for the short-term, these foods became increasingly unaffordable. Taken together it appears that while calorie hunger was likely averted when the pandemic onset, micronutrient malnutrition is expected to have worsened.
What we know about the affordability of healthy diets
Our work in rural India has shown a universal presence of at least one staple cereal—like rice or wheat—on the plate. We also know that most of these small and marginal farming households grow these very same crops. For most of their other food needs however, these households rely on local food markets. These typically are weekly village-level wet markets where perishables like fruits, vegetables, meats, and dairy can be purchased. Such markets can then ensure nutrition security if they can make available a year-round supply of nutritious foods, at affordable prices.
We tracked one dozen wet markets in rural India over a period of twelve months in 2018-19 to understand the level of diversity of foods that are locally available, and to study how their prices fluctuate over time. By merging information on food prices with global dietary guidelines from the EAT Lancet Commission we are able to estimate the cost of healthy diets in our program locations. A healthy diet costs $3.30 per person per day if an individual were to source all their food needs from the market, choosing to consume the cheapest food items across food groups. The cost of the EAT Lancet diet increases to $5.50 per person per day if average-priced items in each food group are consumed. The unaffordability of such diets is evident when compared against welfare measures like the international poverty line ($1.90 per person per day).
It is estimated that nearly 3 billion people around the world cannot afford healthy diets at present. Approximately 1.3 billion of them are estimated to be living in India. Little however is known about the divergence of current diets from recommended ones. TCI’s work in India compared the cost of the EAT Lancet diet to the cost of the current diet of rural households, using primary as well as secondary data on household food expenditures in 2018-19. We find that the actual cost of diets in our program location is valued at $1.00 per person per day. In other words, households will have to spend at least $3.00 more, per person per day in order to meet the EAT Lancet dietary guidelines. These estimates are supported by data at the population level as well where the cost of the current average diet is $1.50 per person per day at present. By disaggregating the cost of diet estimate we know that most of the increased spending needs to be concentrated in three main non-staple food groups: meat, dairy and fruits. We also know that these gaps are driven by both the level of and volatility in prices of these foods.
What we need to do
Food systems at present are struggling to provide nutritious diets to the world’s poorest people. Nutrition security requires a convergence of policies and programs across sectors. While agriculture plays an important role for farming communities, it alone cannot ensure good nutrition for the communities that are engaged in it. Making agricultural policy nutrition-sensitive has to occur even as emphasis is placed on the role of markets in ensuring healthy diets and generating demand for such foods at the community level.
To the extent that small and marginal agricultural communities source their food from own-production, it is essential to diversify the basket of crops being cultivated on the farm. The bulk of the evidence supporting the role of production diversity for improved nutritional outcomes comes from Sub-Saharan Africa. Even so we find that a diversification of the cropping systems in India away from cereals towards pulses and livestock is significantly associated with higher dietary diversity for women and households. Agricultural production in India, that has traditionally been centered around rice and wheat, should be diversified towards cultivation of pulses, fruits and vegetables, and livestock rearing. Some of the next steps for this to happen are ensuring that farmers have access to physical inputs like seeds and irrigation, access to technological knowhow, as well as strengthened linkages to markets through FPOs that reduce transaction costs and ensure price realization.
While a diversified farming system has potential to meet demand for healthy foods, it’s likely to be relevant in environments where markets are weak, resulting in an almost exclusive dependence of households on meeting their consumption needs from their own production. With well-functioning markets, a household’s production decisions become ‘separable’ from its consumption needs. Household market integration can then be an important determinant of their access to a diverse diet that is purchased from local markets. This is evident in the role that market purchase of and expenditure on non-staples like dairy, pulses, eggs and meat play in determining dietary diversity in rural India. Local food markets can be strengthened by investing in infrastructure like roads and transport that make markets accessible to communities. At the same time investments in infrastructure like cold-storage facilities are also essential to ensure that food loss of perishable foods like fruits and vegetables is contained.
In rural India, as in other parts of the world, the poor rely extensively on public food safety nets. These take the form of subsidized ration through the Public Distribution System, hot meals in primary schools through the Mid-Day Meal Program, and on-site cooked food and take home ration for preschool-aged children and their mothers through the Integrated Child Development Services. Such programs offer an existing infrastructure that can be leveraged to ensure that diversified foods can reach young children, and pregnant and lactating mothers.
A diversified production system supported by investments to strengthen local markets can result in an increased supply of diverse, nutritious foods throughout the year. Simultaneously, women’s empowerment is a strong pathway for increasing the demand for diverse foods. Women’s input in agricultural production decisions, their ability to decide how incomes are spent and their workloads all determine food purchase, preparation, and consumption decisions at the household level. Women’s empowerment in agriculture is a strong determinant of women’s dietary diversity. Evidence suggests that diets are more diversified when women are able to participate in decisions related to agricultural production, in nutrition-related self-help groups, and have adequate time for leisure.
At present, there is no country in the world that is on course to meeting the eight 2025 Global Nutrition Targets. Improved dietary quality is an important pathway for making progress towards improved maternal and child health outcomes such as anemia and stunting, amongst others. Improved data systems are crucial for tracking global, national, and subnational progress on such outcomes. For dietary intake this means going beyond data on expenditures and food prices and emphasizing the role of the local food environment and intra-household food allocation in ensuring equitable food intake by all, over time and across geographies.