Shaping India’s nutrition story using behaviour science

With iron deficiency being the most talked about nutrient deficiency in the world, it is no doubt important to bite the bullet of anemia. As per National Family Health Survey (NFHS), close to 59 percent children, 51 percent pregnant women, over 53 percent non-pregnant women are anemic. Moreover, the menace of anemia doubles the risk of death during pregnancy, leads to poor mental growth in children under five years – 38 percent stunted, 36 percent underweight. It is even believed to lower productivity, leading to a loss of upto 4 percent of GDP i.e. Rs. 7.8 lakh crore, which is five times India’s budget for health, education and social protection in 2018-19 ().

On Independence Day this year, our honourable Prime Minister announced the decision to fortify all rice distributed under various schemes by 2024 in order to tackle malnutrition in the country. It is believed that fortified rice (with iron, vitamin B-12 and folic acid) can provide 30 – 50 percent of the daily recommended dietary allowance of iron. This certainly has a distinct edge over supplements, but is this ‘the’ solution for India’s malnutrition problem?

While a pilot has been done in 15 districts, across 15 states, there is little evidence around outcome of fortification. It is perhaps too soon as nutritionists have expressed that a minimum of 24 months of constant exposure to fortified rice is needed in the diet. Concerns around potential harm, if found in excess in some or among those with genetic hemoglobinopathies or with infections such as malaria, pneumonia, diarrhoea have also been expressed. 

Mid-day meals containing rice fortified with essential micro-nutrients were introduced in government schools in Karnataka and Gujarat. Evaluation studies confirmed that daily consumption of fortified rice led to reduction in anemia, and improved nutritional and cognitive indicators. On the other hand in Odisha, additional supplementation provided under the Mid-Day Meal Scheme failed to improve haemoglobin levels on its own. Clearly, much work needs to be done towards evaluating efficacy of fortified rice, before the government adopts a one size fits all approach. In Behaviour Science this is called optimism bias where we tend to underestimate the risks. A case in point being learnings from the iodised salt example which cautions us to varied effects on people, largely because of regional differences in personal food environments and consumption habits.

Micronutrient supplementation can also be achieved by diversification of diets, providing better quality meals. Research in India has shown that states with higher growth in agricultural output have lower stunting rates among children and higher body mass index among women. What we need is a wider set of food and agricultural interventions, to ignite nutrition sensitivity from farm to the fork – spread over food production and supply, to food demand and consumer behaviour. Poverty is a major factor that limits access to adequate nutritious foods. When food prices rise, people continue to eat staple foods while decreasing their intake of non-staple foods that are usually richer in micronutrients. 

Study of human behaviour tells us that to change behaviour we best change the decision environment (the so-called choice architecture) to gently guide people into the desired direction. The desirability for diverse and local vegetables and fruits can be fanned in people by encouraging them to cultivate community gardens. They could use vacant plots of land, common areas. This will allow communities to grow their own local vegetables to eat, thereby improving their dietary diversity and nutrition intake. Teach them to use these vegetables with fortified rice and enjoy wholesome meals. PM Poshan currently is extended to more than 11.20 lakh schools in India. Let’s get the children (future of India) to fall in love with nutrition – teach them to grow, taste and benefit from local, nutrient rich vegetables. Every school should have a community garden where children are taught about vitamins and minerals in a fun way. 

A pilot project was done in Brazil to test a model to scale up rice fortification. Consumers’ strong attachment to rice combined with a weak understanding of micronutrient malnutrition hampered demand creation efforts. It is human behaviour to be naturally averse to ambiguity, especially in situations where we have no control on the outcome or when we do not have enough information. So we tend to avoid such situations and products. Secondly, people seek internal consistency in the way they behave. Hence, it is important for the government to first increase understanding with concentrated efforts to spread awareness about fortified rice, benefits, address concerns (which are many) and loopholes, so that demand is created and acceptability is better. 

Creating small nudges to draw the buyer is important, yet the decision needs to lie with the buyer to make an informed choice. A better understanding of how people make real-life decisions is all it takes to design policies which lead to desired outcomes. 

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