Trends in Nutrition Outcomes and Determinants in India
Source: Flickr, Asian Development Bank

While India has made significant progress in nutrition incomes for women and children over the past ten years, this progress has not been uniform across states, and several regions still lag behind national nutrition and health trends and program implementation.

This is according to the latest research from POSHAN, published in a recent paper covering nutrition trends and determinants in the country from 2006-2016. The report utilizes data from India’s National Family Health Surveys for 2005-2006 and 2015-2016 and the2013-2015 Rapid Survey on Children, as well as a comprehensive review of India’s policies and programs aimed at improving women’s and children’s nutrition outcomes. The paper also examined levels and changes in immediate, underlying, and basic determinants of nutrition and health, based on indicators and formulas taken from UNICEF.

According to the report’s findings, India as a whole has seen substantial progress on a number of nutrition and health incomes over the past decade. Child stunting fell from 48 percent to 38.4 percent, and child underweight rates also declined from 42.5 percent to 37.5 percent. The use of exclusive breastfeeding increased by almost 9 percentage points, and low birthweights in children fell from 21.5 percent to 18.6 percent.

However, national levels of wasting in children increased during the study period, from 19.8 percent to 21 percent. The rates of anemia in women, a major health challenge in India, remained fairly stagnant during the study period; anemia continues to impact almost half of Indian women of reproductive age.

Nationally, the underlying determinants of nutrition improved during the study period. The report finds improvements in women’s education levels and marriage age, both of which impact women’s overall well-being. The number of women with 10 or more years of education grew by 10 –percentage points, while the number of girls getting married before the age of 18 fell by 20 percentage points. The study also reports an increase in access to electricity, safe drinking water, and improved sanitation facilities. However, the authors also emphasize that further efforts and investments are needed in these areas, particularly education and sanitation, in order to ensure continued inclusive improvements in health and nutrition outcomes.

The immediate determinants of nutrition – such as early use of breastfeeding, timely introduction of complementary foods for children, and children’s disease burden – saw mixed results during the study period. Women with low BMI declined from 35.5 percent to 22.9 percent, nationally. The number of women breastfeeding their infants doubled from 23.4 percent to 41.6 percent, but the introduction of appropriate complementary foods for older children declined from 52.6 percent to 42.7 percent. The disease burden for children (including diarrhea and acute respiratory infections) remains low, but did not change much over the study period; thus, further efforts to prevent childhood illnesses are needed to “move the dial” on that indicator.

National coverage of nutrition-specific interventions, such as programs to provide iron-folic acid supplements to pregnant women and immunizations and vitamin A supplements to infants and children, improved throughout the period. However, overall coverage of food supplementation programs (during pregnancy, lactation, and early childhood) remains at only 40-50 percent. In fact, of the 12 nutrition-specific interventions reviewed by the report, only three (institutional delivery, skilled birth attendance, and birth registration) reached 75 percent. Thus, while India’s two national women and child health programs - the National Health Mission (NHM) and the Integrated Child Development Services (ICDS) – attempted to expand coverage from 2006-2016, challenges clearly remain.  The authors identify these challenges as poor policy guidance, lack of financing, poor state-level implementation, and lack of education or positive perceptions that may impact people’s choices to participate in these interventions.

At the state level, the data is much more mixed, with some states attaining more progress in nutrition and health outcomes than others. For example, detailed covered of the many positive results in Gujarat are covered here. A number of states have seen significant progress in reducing stunting, with an average annual rate of reduction (AARR) of 3.8 percent; these states include Himachal Pradesh, Tripura, and Arunachal Pradesh. Other states, including Rajasthan and Jharkand, saw AARR in stunting of only 1 percent. Stunting prevalence also varies considerably between states. For example, stunting in Bihar remained very high in 2016 at 48.3 percent, while Kerala had a stunting prevalence rate of only 19.7 percent. Overall, stunting rates were “very high” in six states, “high” in 12 states, “medium” in 17 states, and “low” in only one state.

The state-level picture is the same for child wasting. Several states, including Meghalaya and Tripura, saw very high AARR in wasting, but other states (including Punjab, Goa, Maharashtra, and Karnataka) actually saw an increase in child wasting over the study period of more than 4 percent annually. Overall at the state level, prevalence of child wasting was very high for 28 states and unions; only six states/unions had high wasting levels, and only two had medium wasting levels. No state or union achieved a “low” rating for child wasting.

While the prevalence of underweight children declined across the board during the study period, the magnitude of that decline varied by state. Prevalence of child underweight remains very high in 14 states, high in 15 states, and medium in 7 states. No state has achieved a “low” rating for child underweight.

Anemia among women of reproductive age remains a significant public health challenge throughout India. At the state level, changes in anemia rates varied from reductions of more than 20 percentage points in Sikkim and Assam to increases of more than 10 percentage points in Himachal Pradesh and Punjab. Thirty states and unions continue to see anemia rates that classify as severe according to the World Health Organization, while six states/unions have moderate anemia rates.

The picture for the underlying determinants of nutrition at the state level is much the same as that for the national level. All states saw an improvement in women’s education level during the study period, and all states except Manipur saw a decline in the number of girls getting married before the age of 18. In addition, the report finds improvements across the majority of states for access to electricity, safe drinking water, and improved sanitation facilities. However, as with the nutrition outcomes at the state-level, the magnitude of these improvements varied across states.

Also mirroring the national results were the state-level results for the immediate determinants of nutrition. Complementary feeding practices are of particular concern for most states; the study found that the timely introduction of complementary foods declined in almost every states during the study period and that children’s dietary quality and frequency remains low. While acute respiratory infections declined in most states, the prevalence of diarrhea actually increased in seven states and union territories.

State-level coverage of nutrition-specific interventions follows the same varied pattern. Coverage of iron-folic acid supplements for pregnant women improved in most states, with 10 states reporting more than 50 percent coverage for 100 days of pregnancy. On the other hand, coverage of interventions aimed at improving rates of institutional delivery ranged from 70 percent to just 7.4 percent. The report suggests that this broad range could be attributed to both differences in program operation from state to state and differences in populations’ decisions to participate in the interventions. Despite this highly variable coverage rate, however, institutional deliveries increased in almost all states, with several states achieving 70 percent coverage or above.

Child immunization rates improved in most states, and coverage of vitamin A supplementation programs increased in all states. However, the report finds that overall coverage of childhood interventions remains lower than interventions during pregnancy. Food supplementation programs for children are particularly varied.

Overall, the report emphasizes that the high variability in nutrition outcomes and determinants at the state level is the most crucial finding for future policymaking. Truly understanding where the challenges and bottlenecks lie to improving nutrition and health outcomes at the state level can signal locations and indicators for which targeted investments can have the most impact. Further state-level analysis of the trends in nutrition outcomes and determinants needs to be conducted. Nationally, efforts are most needed in the areas of complementary child feeding, breastfeeding, improving sanitation facilities, and reducing anemia rates in women. 

Photo credit:Flickr, Asian Development Bank