With one of the highest rates of child malnutrition in the world, India has won notoriety as one of the nutritional basket cases of the world over the past few years. Although India has witnessed significant progress in its battle against child malnutrition over the past decade, the progress has been quite uneven, and child malnutrition rates still remain high in many parts of the country, data from the latest round of the National Family Health Survey (NFHS) shows.

The survey of over 6 lakh households conducted in 2015-16 shows that over the past decade, the proportion of underweight children fell nearly 7 percentage points to 36%, while the proportion of stunted children (those with low height-for-age, a measure of chronic undernourishment) declined nearly 10 percentage points to 38%. Despite the progress, these rates are still higher than those of many poorer countries in sub-Saharan Africa. And in some of the worst affected districts such as Purulia in West Bengal and Nandurbar in Maharashtra, every second child is undernourished.

Such high level of child malnutrition imposes a huge economic cost. Malnutrition accounted for losses worth at least 8% of global gross domestic product (GDP) in the 20th century because of “direct productivity losses, losses via poorer cognition, and losses via reduced schooling", according to medical journal The Lancet, which published a special issue on the topic in 2013. The losses are higher for high-burden countries such as India.

As in the case of adult undernutrition rates, districts with the highest levels of undernutrition seem to be clustered largely in the central parts of the country. The bottom quartile of districts ranked according to child malnutrition rates includes not just districts from the most deprived tribal belts of central and eastern India but also some of the more urbanized districts of the country such as Udaipur in Rajasthan, Aurangabad in Maharashtra, Lucknow in Uttar Pradesh, Patna in Bihar, and Ranchi in Jharkhand. However, overall urban child malnutrition rates are lower than that of rural India.

Districts with relatively low levels of child undernutrition are clustered largely in the extreme north, the extreme south, and in the north-eastern parts of the country, as the district maps show. Some of the best-performing districts in the country with the lowest proportions of underweight children such as Mokokchung in Nagaland and Aizawl in Mizoram lie in North-east India.

Apart from poverty, there seems to be three key differences between districts with high and low levels of child malnutrition: the status of women, the kind of diets fed to children, and access to toilets.

One of the primary reasons for children being undernourished in the country is that often their mothers are undernourished. One in five women are underweight in India. Women who are themselves undernourished or have a pregnancy at an early age, are at a greater risk of delivering low birth-weight babies, who are nutritionally disadvantaged right at birth. Also, women without education or without much voice in their families often fail to ensure adequate diets for their children even when there is adequate food in the household. Districts with a high proportion of women who are illiterate and who have married early tend to have high ratios of undernourished children, the latest data shows. Districts where the proportion of children receiving an age-appropriate diet is low also tend to have high ratios of undernourished children.

The link between sanitation and undernutrition is even stronger. Districts with low levels of access to toilets have much higher rates of child undernourishment compared to districts with relatively high levels of access to toilets. In a densely populated country such as ours, the lack of sanitation contributes to the spread of infectious diseases. Children fall prey more easily to such diseases, and tend to lose their ability to absorb nutrients, leading to undernutrition.

Among states, Tripura and Himachal Pradesh seem to have made impressive strides in improving the rates of both stunting and underweight among children since 2005-06, when the previous NFHS round took place. Tripura has moved up three rungs between 2005-06 and 2015-16 to occupy the third position—behind Kerala and Goa—among states with the lowest levels of stunting. Himachal Pradesh has moved up five rungs over the same period to occupy the fifth position among states ranked according to levels of stunting. States such as Chhattisgarh and Punjab have seen significant improvements in rates of stunting over the past decade but their progress in reducing the proportion of underweight children has been less impressive. Andhra Pradesh and Karnataka have both seen very slow progress in underweight and stunting rates over the past decade, and have slipped several notches in the rankings of states.

Uttar Pradesh, Bihar and Madhya Pradesh have made some progress in the battle against child malnutrition but they continue to be among the worst states in terms of rates of underweight and stunting. They also continue to account for most of India’s undernourished children, as they did a decade ago.

Dipti Jain contributed to this story.

This is the second part of a three-part series on health and social outcomes in India based on data from NFHS 2015-16. The first part of this series looked at the growing problem of obesity among adults. The district-level data for the story has been scraped and visualized by Mint’s partner, HowIndiaLives.

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