Table of Contents
- Introduction: A child can be 'eating well' but not well-nourished
- Why nutrient adequacy is essential
- Dietary diversity: A proxy indicator for diet quality
- What do Indian studies say?
- Key micronutrients and why they are essential
- The problem with the "staple diet"
- How to improve: the power of everyday family meals
- Food combinations and packaged foods
- Responsive feeding
- A 5-question nutrition check for parents
- The bigger picture
- A nutritionist's view
- Key points
- Final message
Introduction: A child can be 'eating well' but not well-nourished
"My child eats three meals a day."
"My child eats enough."
"My child is not undernourished."
While these statements may be understandable, they may lead us to a false sense of security. A child can be eating enough calories but still lack micronutrients.
While severe undernutrition has visible adverse effects, micronutrient malnutrition can occur without visible signs and impact growth, immunity, cognition and more.
We need to think beyond calories and go beyond 'how much' and think about 'what'. Childhood is a critical period of growth and development, and micronutrients play a role in brain development, haemopoiesis, immunity and normal functioning of organs and tissues.
Why Nutrient Adequacy Is Essential
The transition to complementary feeding is critical since the quality of complementary foods affects micronutrient status.
As per a systematic review of trials by Obbagy et al., iron-rich complementary foods can improve iron status or prevent iron deficiency in infants at risk of iron deficiency. Supplementary foods rich in zinc also had moderate evidence of improving zinc status.
This emphasises the importance of the micronutrient density of foods introduced to the child.
Dietary Diversity: A Proxy Indicator for Diet Quality
Dietary diversity refers to consumption of different food groups. It means not relying too heavily on a few food items.
In a 2023 study of 15 articles involving children under five, researchers concluded that there was a positive association between dietary diversity and micronutrient adequacy.
Different foods contribute to diet in different ways:
Cereals and millets: Rice, roti, oats, ragi, jowar, bajra — energy, carbohydrates, some micronutrients and fibre
Pulses and legumes: Dal, chana, rajma, moong — protein, fibre, iron, folate and zinc
Dairy: Milk, curd, paneer — protein, calcium and B12
Eggs: High-quality protein, choline and micronutrients
Vegetables: Carrot, pumpkin, beans, tomato — fibre, carotenoids and folate
Green leafy vegetables: Palak, methi, amaranth — folate and carotenoids
Fruits: Guava, orange, papaya, mango, banana — vitamin C, carotenoids and fibre
Nuts and seeds: Groundnuts, sesame seeds, almonds, walnuts — fibre, protein, healthy fats and micronutrients
Meat and fish: Chicken, fish, meat — micronutrients, protein and haem iron
No single food is an island on its own. Different foods contribute to our micronutrient needs in different ways and variety within food groups is also important.
What Do Indian Studies Say?
A multi-centric study of 1,845 Indian children and adolescents aged 9-18 years found that dietary diversity and food variety were positively associated with mean micronutrient adequacy, growth and haemoglobin.
This is an observational study and therefore it cannot be concluded that increased dietary diversity will lead to an improvement in micronutrient status. However, it does support the notion that a more diverse diet is generally associated with a better micronutrient adequacy.
Another large Indian study (n=73,036) looked at dietary patterns and food groups among children aged 6-23 months who met and did not meet dietary diversity criteria. This further reinforces the importance of a varied diet.
Key Micronutrients and Why They Are Essential
Iron: Iron is necessary for haemoglobin synthesis, oxygen transport, energy metabolism, and brain development. Deficiency can cause anaemia and impair cognition and immunity. Rich sources include dals, chana, rajma, moong, green leafy vegetables, nuts, sesame seeds, eggs, fish, chicken and meat.
Plant-based absorption: Plant-based foods contain non-haem iron, whose bioavailability may be lower than haem iron. Vitamin C-rich foods can enhance absorption. Examples include dal and tomato, chana and lemon, rajma and capsicum, and sprouts and guava.
Zinc: Zinc plays a role in immunity, protein synthesis, cell division and tissue repair. Sources include legumes, nuts and seeds, dairy products, eggs, meat and seafood.
Vitamin A: Vitamin A is essential for vision, immunity and normal growth. Sources include carrots, pumpkin, sweet potatoes, green leafy vegetables, mangoes, papayas, eggs and dairy products. High-dose supplementation should be avoided unless indicated by a healthcare professional.
Vitamin B12: Vitamin B12 plays a role in DNA synthesis and neurological function. It is found exclusively in animal-source foods. Vegan diets may therefore require fortified foods or supplements, as indicated by a healthcare professional.
Calcium and Vitamin D: Calcium is necessary for strong bones and teeth and plays a role in muscle function and nerve signalling. Sources include milk, curd, paneer, ragi and fortified foods. Vitamin D aids calcium absorption and is necessary for strong bones.
The Problem With the "Staple Diet"
Suppose a child's daily meals look like this:
Breakfast: Bread + Jam
Lunch: Rice + Potatoes
Snacks: Biscuits
Dinner: Roti + Potatoes
The problem is not that these are 'bad foods'. The problem is that the diet lacks variety and relies heavily on staple foods such as rice, wheat, bread, and potatoes. It provides little dietary diversity.
How to Improve: The Power of Everyday Family Meals
There is no need to make separate 'child-friendly meals'. We can make the everyday meals that the whole family eats more nutritious.
Instead of bread, have vegetable poha with peanuts and fruit. Instead of rice with potatoes, have dosa with sambar and vegetable chutney. Have healthy snacks like roasted chana, along with fruits and vegetables.
Other options include:
Vegetable poha with peanuts and fruits
Dosa with sambar and vegetable chutney
Rice + dal + vegetables + curd + fruit
Vegetable or methi paratha with curd and fruit
Dal-rice khichdi with vegetables, curd, and fruit
The aim is to make everyday meals more nutritious, not to make children eat a 'perfect' meal.
Food Combinations and Packaged Foods
Pairing iron-rich foods with vitamin C-rich foods can enhance iron absorption. Healthy fats can also be added in right amounts to improve carotenoid absorption.
Not all packaged foods are unhealthy, but relying on them exclusively can reduce dietary diversity and replace healthier whole foods. Highly processed and minimally nutritious packaged foods should be limited rather than allowed to replace wholesome family foods.
Responsive Feeding
Even nutritious meals can become stressful if we are constantly pressuring the child to eat. Responsive feeding encourages offering age-appropriate foods while allowing the child to decide what and how much to eat.
Keep mealtimes regular.
Offer healthy food choices.
Encourage, but do not force the child to eat.
Do not insist that the plate must be empty.
Avoid distractions.
Do not pressure the child to try new foods.
Nutrition is about encouraging healthy habits, not forcing them.
A 5-Question Nutrition Check for Parents
✓ Did my child get a protein-rich food?
✓ Did my child get vegetables and/or fruits?
✓ Did the meal include several food groups?
✓ Did my child consume more packaged foods in place of healthy meals or snacks?
✓ Is my child's growth pattern normal?
The Bigger Picture
A child's diet is only one part of the equation. Conditions such as chronic diarrhoea, infections and malabsorption can affect nutritional status.
If the child has persistent feeding problems or concerns about growth or development, it is best to consult a physician or dietitian. Supplements should be taken only when indicated by a healthcare professional, as excessive supplementation can also be harmful.
A Nutritionist's View
"Make your everyday meals count!" is my advice to parents.
For most parents, the best place to start is right at home, with the food they prepare for their children. We do not always need expensive packaged foods or complicated meals. We can start by making everyday meals more diverse and nutritious.
Add more protein-rich foods to meals.
Incorporate more vegetables and fruits.
Add dairy products wherever possible.
Introduce a variety of foods, including nuts and seeds, as the child grows.
Think about food combinations to get the most nutrition out of a meal.
Do not pressure the child to eat.
Key Points
Calories are important, but a calorie-sufficient diet is not necessarily nutrient-sufficient.
Dietary diversity is associated with micronutrient adequacy in children.
Indian studies confirm that dietary diversity and variety are positively associated with micronutrient adequacy, haemoglobin and growth.
Everyday Indian foods can be leveraged to create micronutrient-dense meals.
Micronutrient supplements can be beneficial but should not be taken in excess.
Final Message
Preventing hidden malnutrition in children starts at home, with our everyday family meals. A diet rich in diverse, nutritious foods can help prevent hidden malnutrition in children.
The magic word is variety. A variety of foods, prepared in a variety of ways makes for a healthy and nutritious diet.
After all, a child can be full, but not nourished, so it is important to think about the foods that we give to our children.
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