Solving the child malnutrition puzzle

Written by Himanshu

The recently released National Family Health Survey (NFHS) 5 data raise serious concerns about India’s growth story. Behind the glitter of the stock market touching new heights, lies the gloomy reality of India’s ballooning childhood malnutrition. In India, 37.8 per cent of children under 5 years of age are stunted. This is 16 per cent higher than the average for Asia (22 per cent). The situation of wasting is no better, with 20.8 per cent of children under 5 years of age affected, which is higher than average for Asia (9 per cent). The Global Nutrition Report, 2020, highlights that 68 per cent of under-5 mortality in India is due to malnutrition. As per the latest NFHS 5 report, over 35 per cent of children under 5 are stunted and over 20 per cent are wasted in 18 out of the 22 states for which data is released. That amounts to 47 million children, the largest in any part of the world. Out of the two, stunting, also known as growth retardation, has serious long-term health and economic consequences.

As countries move up the income ladder, the rates of stunting and wasting declines, a phenomenon observed globally. However, India is an outlier and breaks this causality. States with relatively high per capita incomes have stunting rates comparable to the poorest African countries. In many Indian states, the situation is worse than that of poor sub-Saharan African countries. For instance, Bihar, Manipur and West Bengal have similar per capita income ($) as sub-Saharan African countries — Liberia, Tanzania and Zimbabwe — but, the average stunting rates in Bihar (43 per cent), Assam (35 per cent) and West Bengal (34 per cent) are 10-12 per cent higher than that of Liberia (33 per cent), Tanzania (32 per cent) and Zimbabwe (3 per cent) respectively. The situation is worse when it comes to middle-income states like Goa, Maharashtra, Gujarat, Andhra Pradesh, Telangana and Karnataka with similar per capita income ($) as Peru, Egypt and Morocco. The average stunting rates in Goa (26 per cent) Maharashtra (35 per cent), Gujarat (39 per cent), Telangana (33 per cent) and Karnataka (35 per cent) are almost 10-15 per cent higher than that of Peru (12 per cent), Egypt (22 per cent) and Morocco (15 per cent). Understanding this paradox among Indian states, which has an unusually high level of stunting relative to their economic development, merits investigation.

Despite this high prevalence, India has rarely undertaken a comprehensive study to understand the pathogenesis of stunting. Therefore, what we have is a lopsided understanding of the problem. As per WHO, stunting can be attributable to medical and socio-economic factors. The medical factors include genetics (parents’ height), access to nutrition and mother’s health (anaemia, BMI). Besides, there are economic factors — income, poverty, access to healthcare, mother’s education and labour force participation — and social factors — caste, race, women status and place of residence etc. Of these, which ones are proximate and which one the distant factors, we simply don’t know.

Based on this conceptualisation, economic factors like average per capita income and prevalence of multi-dimensional poverty are loosely correlated with the prevalence of high stunting in states of AP, Telangana, Gujarat, Maharashtra & Karnataka. Similarly, maternity care characteristics (ante-natal care during pregnancy, post-natal care and consumption of folic acid during pregnancy), although extremely important, but, are weakly associated with high stunting rates in these states. Despite relatively modest economic growth and favourable maternity characteristics, high prevalence of stunting in these states defies logic. After all, these states have been the flagbearers of India’s growth story since 1991.

In popular parlance, poverty is synonymous with stunting. Poor households and poor states are expected to have stunted children. But what could explain significantly higher stunting rates in middle-income states?

First, women’s educational status, especially secondary and above, along with female labour force participation partly resonates with high stunting rates. Maternal literacy is an important determinant of a child’s nutritional status. Literate mothers are expected to be aware of their health, nutrition and breastfeeding practices. This finding, however, reflects the tragic reality of women bearing the undue burden of childcare. Second, the mother’s health, the prevalence of anaemia in women of reproductive age. India is one of the most anaemia-prone countries in the world. Children under age 5 and women of productive age are particularly vulnerable. Several studies have explored the strong association between stunting and the presence of anaemia in women of childbearing age. For instance, women of low BMI had greater odds of developing anaemia and the children of anaemic mothers are at greater risk of being stunted. The implication, a vicious circle of anaemia and stunting — stunted children of anaemic mothers are at greater risk of developing anaemia. The NFHS 5 data corroborate this finding — all women in reproductive age who are anaemic stands at 59 per cent in Andhra Pradesh, 40 per cent in Goa, 63 per cent in Gujarat, 48 per cent in Karnataka, 55 per cent in Maharashtra and 58 per cent in Telangana.

Third, urban slums and lack of sanitation is a potential contributor to stunting. Despite claims, India still lags behind sub-Saharan African countries in terms of safely managed sanitation services. States like Maharashtra, Andhra Pradesh, Telangana, Karnataka have a significant population living in urban slums who do not have access to improved sanitation facilities. The difference in sanitation practices between Indian states and their African counterparts explains the difference in stunting rates.

The other, atypical factor that has an impact on the prevalence of stunting is genetics (mother’s height). As per WHO, the golden rule of measuring stunting in children is the height for age Z score (HAZ). A child is considered stunted if the HAZ score is two standard deviations below the median of WHO child growth standard. The height of children is closely associated with the height of mothers. For instance, the average female height in South Asia, including India, is approx. 150-156 cm, whereas, the average female height in Europe and Africa is 164-168 cm and 160-165 cm respectively. Genetic differences can explain the differences in the stock of stunted children in two regions, but it can’t be the dominant factor in explaining the flow of stunted children. The analysis, then, boils down to the real culprits — anaemia and low BMI among women, social and gender inequalities, which together manifest in the problem of malnutrition among children.

(The writer is an economist with Swaniti Initiative, previously worked with Prime Minister Economic Advisory Council, Government of India & FAO of United Nations. Views are personal)

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