As compared to the period between 2006 to 2015, the pace of reductions in child stunting and underweight across Indian states have slowed whereas the rise of child overweight has accelerated between 2015 and 2020. These changes disrupt favourable trends that included large reductions in undernutrition and stability of overweight observed in the preceding time period between 2006 to 2015. Our findings also indicate that India is likely to fail in achieving the national targets set by the National Nutrition Mission (POSHAN Abhiyaan) for stunting, wasting, and underweight of ~ 23%, ~ 7%, and ~ 21%, respectively, by year 2022 (15, 18). While there is no national target for the prevalence of child overweight in 2022, and the projected prevalence in 2022 (5.2%) is estimated to be close to the LMIC average in 2017 (6.0%), the rise in the proportion of overweight children is expected to offset any reductions in undernutrition (19–21). The total prevalence of unhealthy weight among children in India will likely remain a concern (22, 23). We also found that both undernutrition and overweight increased in urban areas. If current trends continue, the gap between child stunting in urban and rural areas will reduce by nearly 4 pp by 2022.
The stalled progress in undernutrition occurred against the backdrop of improvements in 7 of 9 development indicators from 2015 to 2020. Our findings highlight a potentially worrisome disconnect between the apparent expansion of human development and improvements in child nutrition outcomes (24). Specifically, the bivariate decomposition analysis predicted moderate to large declines in population-level undernutrition based on the rise in favourable development indicators such as women’s literacy and households with electricity. Our analyses showed that these predicted reductions in undernutrition did not occur. Moreover, overweight is rising at a rate that is greater than what would be expected by improvements in human development observed in the past 5 years. The higher than expected prevalence in all four measures of unhealthy weight in children may imply that overall improvements in standard of living and human capital did not materialize in gains for child nutrition.
The observed stagnation in reductions in child undernutrition are consistent with data suggesting a reversal in the decline in annual infant mortality rates (25). Our results are also consistent with studies conducted in other contexts that have shown limited reductions in the prevalence of stunting despite implementation of successful nutrition-sensitive and nutrition-specific interventions (26).
Child wasting, measured as weight-for-height, reflects current deficits in tissue and fat mass. Wasting has also demonstrated a small but statistically significant lagged association with linear growth status, measured as length-for-age especially for children aged 1 year or less, which is a marker of long-term undernutrition (27, 28). Therefore, the apparent rise in wasting may be a predictor of future stunting at the population level. Prior literature suggests that the prevalence of stunting in India is not susceptible to seasonal variability while the prevalence of wasting tends to be 5–10% higher between June to December compared to January to May, due to seasonal variation in food availability and infectious disease (29). Given that phase 1 of NFHS-5 (which is all that is currently available) was conducted in most states from June to December 2019, it is possible that the observed prevalence of wasting is an overestimate. Nevertheless, the unchanged national prevalence of stunting between rounds with one-fourth of districts experiencing a rise in prevalence of more than 5 percentage points is concerning.
Our analysis has several strengths. We used the latest available data to evaluate and benchmark ongoing efforts to reduce child malnutrition in India, and priority setting for global reductions in child undernutrition. The application of decomposition analysis permitted us to explore the hypothetical reductions that should have been achieved based on improvements in human development indicators in the population. However, our analyses must be interpreted in light of data limitations. In order to produce timely results that can inform relevant decisions including equitable allocation of funds to programs and states, we analysed aggregated data released at the state and district levels with varying precision of estimates as seen for NFHS-3 and NFHS-4 (Supplementary File 2, Supplementary File 3). This precluded more sophisticated hypothesis testing regarding the secular trends in child nutrition indicators. Such testing may be done once individual-level data become available in the future. Data on indicators from states with a high burden of undernutrition, such as Uttar Pradesh, Madhya Pradesh, Rajasthan, Chhattisgarh, Jharkhand and Uttarakhand, were not collected in Phase 1 of NFHS-5 and were excluded from the current analysis (30). This may skew predicted national level prevalence for 2022 as these high-burden states would be expected to demonstrate the most gains from a comprehensive intervention package as proposed by POSHAN Abhiyaan. We could not explore the association of changes in micronutrient supplementation and of provision of supplementary nutrition with changes in malnutrition outcomes due to data unavailability (31). Finally, our decomposition analysis described associations between human development indicators and child nutrition measured over the same time period. In doing so, we were not able to evaluate a lag between human development and improvements in child undernutrition.
A recent analysis of five LMICs that achieved substantive reductions in child stunting suggest a combination of direct (nutrition-specific) and indirect (nutrition-sensitive) health and nutrition interventions (32, 33). Our findings underscore the importance of targeted monitoring of nutrition outcomes, and support of nutrition sensitive and specific interventions, to address the high and persistent burden of child undernutrition (34, 35). Attention to child nutrition will be even more important in the coming years in light of the unprecedented economic and psychosocial strain of the ongoing COVID-19 pandemic (36). Projections show that in the absence of additional social safety net programs to tackle mounting food insecurity and financial distress incurred through theCOVID-19 related economic shut down, there may be a doubling of the number of wasted and stunted children in South Asia alone by 2022 (37). Given that parts of India which experience the highest burden of child undernutrition also tend to be the most vulnerable to loss of life from COVID-19, it is important to focus on inter-ministerial efforts to curb the pandemic while at the same time avoiding reversal of gains made in alleviation of undernutrition (38).
In summary, the observed slowing progress in measures of child undernutrition warrants further exploration when considered against apparent indicators of progress. Further investigation is prudent to determine whether inequitable human development across segments of the population, or broader social and economic shocks (such as demonetization) are driving the stalling rates of reductions in undernutrition. Furthermore, investigation of outcomes beyond anthropometric growth, such as cognition, would provide a more comprehensive picture of the impact of changes in socioeconomic conditions on child social and developmental outcomes.