New India National Family Health Survey data shows worrying trends on anemia, overweight

Children's heights are a bellwether indicator for all the things that can go wrong, or right, in society. As IFPRI researcher Jef Leroy put it, poor child growth is like a smoke alarm: It tells you there is a fire burning somewhere. Then it can take some detective work to figure out where that fire is, its source, and to identify how to put it out. India certainly has smoldering fires, as indicated by the just-released first set of state and district fact sheets from the fifth round of the National Family Health Survey (NFHS-5). Careful analyses of the data can help tell us both where the fires of malnutrition are burning and to begin to understand the potential causes.

On Dec. 12, the NFHS-5 released factsheets for 22 states and union territories. Our research team did a rapid analysis to examine trends between the NFHS-4 in 2015-16, and the NFHS-5 in 2019 for select nutrition and health outcomes. We also examined trends on immediate and underlying determinants of nutrition, and on the coverage of nutrition interventions.

Together, these factsheets from the extensive NFHS-5 survey provide an important emerging picture of the trends in malnutrition in India. While many states have made progress on key indicators, anemia levels remain largely stagnant and overweight is rising nationwide. Understanding the reasons for these trends will require much more work to explain fully. However, when these early findings are examined against what we know about the determinants of child undernutrition in India and the drivers of change in malnutrition, they can help identify directions for further inquiry and action.

Here are key highlights from the analyses: 

Malnutrition outcomes for children and adults: Child anthropometric outcomes (stunting, wasting and underweight) are worsening across several states, while others, including the large state of Bihar, show noticeable improvements. Mortality indicators in most states show improvements, with more states improving on infant mortality and under-5 mortality than on neonatal mortality. Anemia has increased in most states for children, adolescents, non-pregnant women and men, but has declined in many states among pregnant women. Overweight has increased in most states and among all population groups, including children under 5, adult women and adult men.

Immediate determinants of child undernutrition: Exclusive breastfeeding and adequacy of complementary foods have improved, although levels remain too low. A mixed picture emerges in early initiation of breastfeeding and in timely introduction of complementary feeding, with several states seeing a decline. Maternal nutrition, a known immediate determinant of child outcomes at birth, remains a challenge. Despite reductions in maternal underweight, the levels of maternal anemia are high across many states. Unfortunately, an increase in women’s overweight is a real challenge in many states and also has implications for the health of newborns and infants.

Underlying determinants of child undernutrition: We see large and consistent improvements across all states in water and sanitation indicators, reaching high levels of coverage. This is very promising. There is also a consistent, but small, improvement across states in women’s education and in marriage before the age of 18 years for those aged 20-24 years. However, there remains much room for improvement, especially regarding early marriage, which we and others have shown previously is a key challenge area for nutrition. On the final important determinant of childhood undernutrition—poverty and food security—unfortunately, the fact sheets contain no data on those subjects or on reductions in economic inequity over this period. However, evidence of India’s economic challenges in the 2014- 2019 time frame, including high levels of unemployment and food inflation, suggest large numbers of households were affected negatively.

The reach of key interventions in the health and nutrition sector: We find a mixed picture but a generally positive trend, including on some programs promoted by India’s National Nutrition Mission. Overall, intervention coverage improved in most states, including for early antenatal care and previously stubborn indicators such as the consumption of iron supplements during pregnancy. The completion of four antenatal care visits and the use of zinc with oral rehydration solution require more attention. The fact sheets do not include data on interventions delivered by the Integrated Child Development Services (ICDS), such as food supplementation, health and nutrition counseling, and screening for malnutrition.

The stagnation in anemia levels and the consistent increase in overweight are major concerns for India’s progress towards eliminating all forms of malnutrition. These areas require much more investigation, as we have fewer success stories to learn from. However, from IFPRI’s Stories of Change initiative on success cases in malnutrition, and from the Exemplars in Global Health, we have insights on actions from many countries and Indian states that successfully reduced stunting in the last decade or so that may prove useful in addressing other forms of malnutrition. In our research in Odisha, Chhattisgarh, Tamil Nadu and Gujarat, we find that successful stunting reduction came primarily from improvements in the following three areas:

1. Delivery of high impact health and nutrition interventions, especially to pregnant women and young children.
2. Investments in girls and women throughout their lives, reflected in attained education, reduced early marriage, improved maternal nutritional status and access to health and nutrition care;
3. Equity-enhancing social programs to reduce poverty and improve food security, as well as consistent economic growth.

Even as we await the second wave of the NFHS-5 in mid-2021 and the release of unit-level data, there is no time to lose in taking action. As India looks ahead in the context of a pandemic with dire economic and social consequences, here are some recommendations from the consensus-based Commitment to Action from India’s nutrition policy community:

1. Ensure that nutrition stays on top of the policy, political, bureaucratic and social agenda—all of us have a role to play here!
2. Continue to strengthen existing health and nutrition services to deliver high impact interventions already in the National Nutrition Mission framework—these must reach every woman, every child now and for the next several years.
3. Finance adequately for nutrition: This is budget season in India and health/nutrition and social welfare programs to reach the vulnerable must receive top priority.
4. Ramp up quickly to tackle the underlying poverty, food security, and gender issues because these have been central to addressing poverty and food security in successful cases around the world.
5. Invest in data. Without knowing how well, or how poorly, families with young children are doing, we are flying blind.
6. Strengthen the focus on reaching every 1000-day household with the full suite of existing programs in India's public support portfolio.

This is not the time to seek new magic bullets for child undernutrition—there are none for outcomes such as child growth. However, it is time to make sure that all the available information and evidence at our disposal are deployed to their full potential—both on actions that drive overall success and on states’ specific challenges. Progress in many states shows that change is possible in improving child undernutrition. Bihar’s success, for example, demonstrates that achieving even small changes in places with large populations can help to deliver success for India.

The challenges ahead—both on research and on action—is massive. We invite researchers across India and globally to join hands with us to continue to explore the NFHS-5 and other datasets. Together, we should aim to deliver a collective set of insights on all forms of malnutrition to help provide direction to solving what remains one of India’s biggest challenges.

Purnima Menon is a Senior Research Fellow with IFPRI's Poverty, Health and Nutrition Division (PHND) based in the South Asia Office in New Delhi; Phuong Hong Nguyen is a PHND Senior Research Fellow; Rasmi Avula is a PHND Research Fellow in New Delhi; Esha Sarswat is an IFPRI Communications Specialist in New Delhi. 

A recent version of the slides shared at the webinars this past week is available here. A video from one of the reflections meetings is available here.

IFPRI is continually working to update the analysis. Our team will be happy to share the most updated findings on regular intervals with the research and policy community. If you are interested in collaborating with us or wish to receive the most updated slide-deck, please email IFPRI-POSHAN@cgiar.org.