India's irresponsible Dietary Guidelines

Author: Sylvia Karpagam (public health doctor, India) with input from other members of the Working Group on Health and Nutrition; a longer version of this piece was originally published in South First; re-used here with permission on 28/11/2024.

 

In April 2024, the Dietary Guidelines for Indians were released by the ICMR-National Institute of Nutrition, a public health, nutrition and translational research centre, and the apex body for India's dietary guidelines [DGI 2014]. Unfortunately, the document fails to do due diligence and selectively quotes data from the Comprehensive National Nutrition Survey (CNNS), which provides nutritional and anthropometric data on children and adolescents [CNNS 2019].

The document claims that severe forms of undernutrition have largely disappeared and only ‘subclinical manifestations of undernutrition and anemia persist as public health issues’. In reality, data from this same CNNS show that among Indian children younger than five, 36% suffer from stunting (below 2SD for height expected for age) and 33% are underweight (below 2SD for weights expected for age). This problem was even higher among children from marginalised communities, i.e., 48% of the children from the poorest wealth quintile compared to 19% within the richest quintile. India ranks 105 out of 127 countries in the 2024 Global Hunger Index [GHI 2024].

According to the CNNS, only 21% of the infants and toddlers (aged 6-23 months) were fed an adequately diverse diet, only 6% had received a minimum acceptable diet and only 9% had received iron-rich foods. Among school-age children and adolescents, cereals were the most commonly consumed food group (>85%) in most states, while eggs, fish, chicken or meat were least commonly consumed (<5%). Rather than recognising the time-tested and acute indicators of heights and weights, the DGI insisted on the importance of cholesterol, triglycerides, diabetes, hypertension, etc.

The guidelines tend towards vegetarianism

In its definition of a healthy meal/food the DGI mention only vegetables, whole grains, pulses or beans, nuts or seeds, fruits and yoghurt with no sugar and minimal oils and fats. Eggs, fish, meat and poultry sometimes appear in footnotes or disappear completely.

Yet, the CNNS data showed deficiency incidences of 16-22% for vitamin A, 14-24% for vitamin D, 17–32% for zinc, 14-31% for vitamin B12 and 23-37% for folate, indicating a highly concerning prevalence of malnutrition among children of 0-19 years. An important solution to such widespread malnutrition would be to increase the availability of animal source foods, which provide key nutrients in a digestible and bioavailable form. While plant foods do of course also contain some of these nutrients, their digestibility and absorption can be limited by anti-nutritional factors like lectins, phytates, tannins, oxalates etc. As mentioned in the DGI, processes such as germination and fermentation can improve absorption. The DGI acknowledges that limited availability and high cost of pulses and meat makes a significant proportion of the Indian population rely heavily on cereals, resulting in a poor intake of many essential nutrients.

ICMR-NIN seems conflicted on what stance to take with regard to animal source foods. At one point (p. 9), the guidelines mention that meat, poultry, fish and eggs are the best sources of protein and that the protein in pulses and nuts are limited in some essential amino acids. On another page (p. 58), they mention that 700-900 g of meat, eggs, fish or poultry should be consumed per week. Then in the recommendations for a balanced diet, they leave out these foods and instead mention in fine print below the table that 30 g of pulses/dal can be substituted with fish, chicken, meat or egg for non-vegetarians. Using meat, eggs, fish, etc, interchangeably with pulses shows a poor understanding of the basic principles of nutrition and are concerning, given that these are official guidelines released by the only premier nutrition institution in the country. How can 30 g of pulses be nutritionally equivalent to meat? Vitamin B12, of which there is a deficiency as per the CNNS data, can only come from animal source foods. These ‘guidelines’ will likely be used to frame larger nutritional policies for the country.

Furthermore, the dietary recommendations mention in fine print that ‘non-veg items like fish, egg, chicken can be consumed as per social acceptability and availability’. Does this mean that if vegetarian policy makers and food contractors do not find eggs acceptable (as is very often the case), then they will not be given to children as part of the school mid-day meal?

Attempts underway to erase anemia

The DGI has declared that anemia is now ‘sub-clinical’. Data however shows a prevalence of 24–41%, most prevalent in children from the scheduled tribes/castes. Anemia is, in fact, a moderate or severe public health problem in a majority of states in India. The dietary guidelines blame unhealthy, ultra-processed foods for anemia and folic acid deficiency, rather than the fact that most Indians lack diversity in their meals and suffer from a lower access to nutrient-dense foods, especially haem-rich foods like red meat and organ meats. 

Conclusion

These dietary guidelines are concerning and irresponsible to say the least, relegating nutrient-dense animal source foods like meats, eggs, and fish into the footnotes or small print. They even go to the extent of erasing data on undernutrition, stunting and other deficiencies. Following the pandemic and stringent lockdowns, during which people lost jobs and access to basic foods, these indicators could have only worsened.

Although officials claim that the DGI are diverse and flexible, in reality they seem to want to maintain the mythological bubble of Indian vegetarianism and keep multinationals and corporates happy. Erasing anthropometry and denying data only makes malnutrition invisible on paper, not in reality. The DGI not only influence personal choice, but also educational policies, food schemes and  ‘health education’ messages. The NIN must start legitimising nutrient-dense animal source foods for the management of stunting, undernutrition and anemia rather than formally dismissing them to ‘subclinical’ issues.