India’s healthiest children live in its north-eastern states and Kerala, an analysis of a new national survey conducted by the government shows, but children in these states are also at greater risk of ‘lifestyle diseases’. However, some of the most affluent states - particularly Gujarat, Maharashtra and Haryana - perform the worst on both sides of the spectrum; Gujarat is the country’s unhealthiest state for children.

Released earlier this month, the Comprehensive National Nutrition Survey (CNNS) collected primary information on the medical health and allied behaviours from over 1.12 lakh children between the ages of 0 and 19 across 30 states. The CNNS expands on the data covered by key past health surveys, including the National Family Health Survey, to give a more rounded and more detailed look into the health and lives of India’s children. It includes an expanded range of anthropometric measures to comprehensively capture malnutrition and previously unstudied micronutrient deficiencies.

To come up with a composite health indicator, we aggregated over 50 indicators to create six sub-indicators — diet, malnutrition, iron deficiency, micronutrient deficiency, non-communicable diseases and obesity — and ranked all 30 states on each indicator and sub-indicator. From the six sub-indicators, we composed a final ranking.

The diet sub-indicator looked at four indicators that deal with healthy eating practices and the composition of meals. The malnutrition sub-indicator looked at 17 indicators that dealt with different anthropometric measures of malnourishment, including both traditional measures, like height-for-age (stunting) and weight-for-age (wasting), and less commonly used measures, such as waist circumference and body fat. The anaemia and iron deficiency sub-indicator comprised of six indicators while the micronutrient indicator looked at deficiencies comprising 18 indicators including levels of Vitamin A, vitamin B12, zinc, and sodium. The non-communicable disease indicator looked at 19 indicators pertaining to diabetes, hypertension, cholesterol and other conditions. Finally, the obesity sub-indicator used a range of anthropometric measures to consider 13 indicators of weight. The indicators dealt with children in three groups - those aged 1-4, those aged 5-9 and adolescents aged 10-19.

Unsurprisingly, the better off states including those in the south and north-east have India’s healthiest children, and the Gangetic belt states have among India’s least healthy children. However, there are some significant exceptions. For instance, West Bengal and Odisha do better at ensuring young children have a diversified diet, relative to its income. In addition to the poorer northern states, richer states like Maharashtra, Telangana, Gujarat and Andhra Pradesh feature in the bottom of this distribution. These same states do poorly at ensuring children receive iron-rich foods (natural, homemade or fortified). Even in the rest of the number, the numbers are stark; just three states manage to ensure that even one out of five children between the age of 6-23 months gets a minimum acceptable diet.

As a result, India continues to make very little progress on anaemia; the fourth round of the National Family Health Survey found that the prevalence among women fell by just two percentage points and that among men by one percentage point between 2005-06 and 2015-16. Prosperous states including Punjab, Haryana and Gujarat have a high prevalence of anaemia and iron deficiency among children.

The CNNS also makes significant progress in measuring a range of vital micronutrients in the bodies of children, beyond iron which can be critical for health. “While deficiencies of individual micronutrients can have an adverse effect, multiple micronutrient deficiencies can have a disabling effect on children and adolescents even when deficiencies are mild to moderate," the report notes. In Gujarat, over a quarter of all children are deficient in Vitamin D and over 50% of adolescents aged 10-19 are deficient in zinc. West Bengal is the best-performing state on this sub-indicator, despite its relatively lower prosperity.

Across a range of new anthropometric measures approved by World Health Organization, the northern states and Gujarat fare the worst. These results also reinforce the well-studied idea that heights in India are not purely genetically determined. Children in the north-eastern states are less likely to have abnormally low height for their age than those in the northern states.

Yet, the states that provide better nutrition to children are also at risk of obesity and the precursors to non-communicable ‘lifestyle diseases’. For instance, over 10% of adolescents in Delhi are classified as hypertensive (high blood pressure), and nearly a quarter of 5-9 year-olds in Sikkim and West Bengal have high cholesterol.

Managing these new threats, that are typically associated with richer countries, will be an important public health challenge for states that are doing a better job of caring for their poor; the greater challenge lies before states failing at both ends.

This is the first of a three-part series on insights from the Comprehensive National Nutrition Survey.

Rukmini S. is a freelance journalist based in Chennai.

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