Changes in Child Undernutrition and Overweight in India From 2006 to 2021: An Ecological Analysis of 36 States

Jithin Sam Varghese; Aashish Gupta; Rukshan Mehta; Aryeh D. Stein; Shivani A. Patel

doi:10.9745/GHSP-D-21-00569

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FIGURE
District-Level Changes in Child Growth Indicators in India, 2016–2021: (A) Stunting; (B) Wasting; (C) Underweight; (D) Overweight
Abbreviation: PP, percentage points.

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TABLE 1.

Prevalence and Change in State-Level Growth Indicators Among Children Aged Younger Than 5 Years in 36 States in India, 2006–2021^a

	2006 Prevalence, % (95% CI)	2016 Prevalence, % (95% CI)	2021 Prevalence, % (95% CI)	2006–2016^bAnnualized Change, PP (95% CI)	2016–2021^bAnnualized Change, PP (95% CI)	P Value for Overall Difference in Annualized Change^c	P Value for Within-State Difference in Annualized Change^c(n=30)	Poshan Abhiyaan Target for 2022^d
All India
Stunting	47.8 (47, 48.7)	38.4 (38, 38.7)	35.5 (35.1, 35.8)	−0.9 (−1.0, −0.9)	−0.6 (−0.7, −0.5)	.10	<.01	26.4
Wasting	20.0 (19.4, 20.6)	21.1 (20.8, 21.4)	19.3 (19, 19.6)	0.1 (0, 0.2)	−0.4 (−0.4, −0.3)	<.05	.17	9.1
Underweight	42.4 (41.6, 43.3)	35.7 (35.4, 36.1)	32.1 (31.8, 32.5)	−0.7 (−0.8, −0.6)	−0.7 (−0.8, −0.6)	.42	.09	23.7
Overweight	1.5 (1.4, 1.7)	2.1 (2.0, 2.2)	3.4 (3.3, 3.6)	0.1 (0.0, 0.1)	0.3 (0.2, 0.3)	.22	<.01	-
Rural
Stunting	50.5 (49.6, 51.5)	41.1 (40.8, 41.5)	37.3 (36.9, 37.7)	−0.9 (−1, −0.8)	−0.8 (−0.9, −0.7)	.27	<.01	29.1
Wasting	20.9 (20.2, 21.6)	21.5 (21.2, 21.8)	19.5 (19.1, 19.9)	0.1 (0, 0.1)	−0.4 (−0.5, −0.3)	.06	.56	9.5
Underweight	45.6 (44.6, 46.5)	38.2 (37.9, 38.6)	33.8 (33.4, 34.1)	−0.7 (−0.8, −0.6)	−0.9 (−1.0, −0.8)	.29	.02	26.2
Overweight	1.2 (1.1, 1.4)	1.8 (1.7, 1.9)	3.2 (3.1, 3.3)	0.1 (0, 0.1)	0.3 (0.2, 0.3)	−.23	<.01	-
Urban
Stunting	39.5 (37.9, 41.0)	31.0 (30.3, 31.8)	30.1 (29.3, 30.9)	−0.8 (−1, −0.7)	−0.2 (−0.4, 0)	.01	.01	19
Wasting	17.0 (16.0, 18.1)	20.0 (19.4, 20.7)	18.6 (18.0, 19.2)	0.3 (0.2, 0.4)	−0.3 (−0.5, −0.1)	.02	.16	8
Underweight	32.7 (31.2, 34.2)	29.1 (28.4, 29.8)	27.4 (26.6, 28.1)	−0.4 (−0.5, −0.2)	−0.4 (−0.6, −0.1)	.49	.79	17.1
Overweight	2.6 (2.1, 3.0)	2.8 (2.5, 3.0)	4.2 (3.9, 4.5)	0 (0, 0.1)	0.3 (0.2, 0.4)	.17	<.01	-

Abbreviations: CI, confidence interval; NFHS, National Family Health Survey; PP, percentage points; SD, standard deviation.
↵^aValues are survey-weighted estimates and 95% confidence intervals. Data for 2006, 2016, and 2021 come from NFHS-3, NFHS-4, and NFHS-5, respectively. Child stunting was defined as height-for-age < −2SD, child wasting was defined as weight-for-height < −2SD, child underweight was defined as weight-for-age < −2SD, and child overweight was defined as weight-for-height > 2SD.
↵^bAnnualized change is mean annual absolute change in prevalence for 36 states reported by NFHS surveys in percentage as (%) per annum.
↵^cThe overall difference for 2006–2016 and 2006–2021 annualized change estimates was tested using z-tests. Within-state differences for 2006–2016 and 2006–2021 annualized change estimates were tested using paired Wilcoxon signed-rank test for 30 states which were available across rounds; Andhra Pradesh values used for Telangana.
↵^dPOSHAN Abhiyaan target is estimated as prevalence in 2016 minus targeted annual reduction of 2% for stunting and underweight in children. We additionally used a target of 2 percentage points per year for wasting.
Note: Additional details on geographical boundaries are presented in Supplement 1 Note 1.

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TABLE 2.

Change in Human Development Indicators in 36 States in India, 2006–2021^a

	2006 Prevalence, % (95% CI)	2016 Prevalence, % (95% CI)	2021 Prevalence, % (95% CI)	2006–2016^bAnnualized Change, PP (95% CI)	2016–2021^bAnnualized Change, PP (95% CI)	P Value for Overall Difference in Annualized Change^c	P Value for Within-State Difference in Annualized Change^c (n=30)
Women who are literate	55.1 (54.1, 56.1)	68.4 (68.1, 68.7)	71.5 (71.2, 71.7)	1.3 (1.2, 1.4)	0.6 (0.5, 0.7)	.06	<.01
Women with 10 or more years of schooling	22.3 (21.5, 23.1)	35.7 (35.3, 36.1)	41 (40.7, 41.4)	1.3 (1.2, 1.4)	1.1 (1.0, 1.2)	.28	.6
Women aged 20–24 years first cohabiting after age 18 years	55.5 (54.3, 56.7)	74.7 (74.3, 75.2)	77.7 (77.3, 78.1)	1.9 (1.8, 2.1)	0.6 (0.5, 0.7)	<.01	<.01
Female children at birth for children born in last 5 years^d	47.9 (47.3, 48.4)	47.8 (47.5, 48.0)	48.1 (47.8, 48.3)	0 (−0.1, 0.1)	0.1 (0, 0.1)	.44	.24
Population living in households that use improved sanitation facility	29.5 (28.4, 30.7)	48.5 (48.0, 49.0)	70.2 (69.8, 70.5)	1.9 (1.8, 2.0)	4.3 (4.2, 4.5)	<.01	<.01
Population living in households with improved drinking-water source	88.2 (87.4, 89.0)	94.4 (94.2, 94.6)	95.8 (95.6, 95.9)	0.6 (0.5, 0.7)	0.3 (0.2, 0.3)	.23	<.01
Population living in households with electricity	67.2 (65.9, 68.5)	88.0 (87.7, 88.3)	96.8 (96.7, 96.9)	2.1 (1.9, 2.2)	1.8 (1.7, 1.8)	.25	<.01
Households using clean fuel for cooking	25.5 (24.3, 26.8)	43.9 (43.2, 44.5)	58.8 (58.3, 59.3)	1.8 (1.7, 2.0)	3.0 (2.8, 3.1)	<.01	<.01
Households with any usual member covered under health insurance or financing scheme^e	5.0 (4.6, 5.4)	28.8 (28.5, 29.2)	41.2 (40.9, 41.5)	2.4 (2.3, 2.4)	2.5 (2.4, 2.6)	.42	.76
Human development composite score^f		−0.1 (−3.8, 3.8)	1.4 (−1.7, 4.3)

Abbreviation: CI, confidence interval; PP, percentage points.
↵^aData for 2006, 2016, and 2021 come from NFHS-3, NFHS-4, and NFHS-5, respectively. Additional details on geographical boundaries are available in Supplement 1 Note 1.
↵^bAnnualized change is mean annual absolute change in prevalence.
↵^cThe overall difference for 2006–2016 and 2006–2021 annualized change estimates was tested using z-tests. Within-state differences for 2006–2016 and 2006–2021 annualized change estimates were tested using paired Wilcoxon Signed-Rank test for 30 states which were available across rounds; Andhra Pradesh values used for Telangana.
↵^dSex ratio can be derived using this indicator.
↵^eAyushman Bharat-PMJAY was not fully rolled out at time of NFHS-5.
↵^fMedian (2.5 percentile, 97.5 percentile). Score was created using indicators from NFHS-4 districts as reference.

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TABLE 3.

Expected and Observed District-Level Changes in Child Growth Indicators Associated With Changes in Human Development Indicators, India, 2015–2016 and 2019–2021 (n=640 Districts)

	Stunting^a		Wasting^a		Underweight^a		Overweight^a
	Observed Change −2.5%		Observed Change −2.2%		Observed Change −3.3%		Observed Change 1.7%
Observed Percentage Point Change, Mean	Expected Change, PP (95% CI)	Difference Between Observed and Expected Change^b2016–2021, PP (95% CI)	Expected Change, PP (95% CI)	Difference Between Observed and Expected Change^b2016–2021, PP (95% CI)	Expected Change, PP (95% CI)	Difference Between Observed and Expected Change^b2016–2021, PP (95% CI)	Expected Change, PP (95% CI)	Difference Between Observed and Expected Change^b2016–2021, PP (95% CI)
Mean human development, composite score	−5.1 (−5.9, −4.3)	2.6 (1.8, 3.4)	−1.7 (−2.0, −1.3)	−0.5 (−1.3, 0.3)	−5.5 (−6.3, −4.7)	2.2 (1.2, 3.3)	0.6 (0.4, 0.7)	1.1 (0.8, 1.4)
Percentage of women who are literate	−1.7 (−2.4, −1.0)	−0.9 (−1.8, 0)	−0.6 (−0.8, −0.4)	−1.6 (−2.4, −0.7)	−1.9 (−2.5, −1.2)	−1.4 (−2.4, −0.4)	0.2 (0.1, 0.3)	1.5 (1.2, 1.8)
Percentage of women with 10 or more years of schooling	−2.3 (−3.0, −1.6)	−0.2 (−1.0, 0.5)	−0.8 (−1.0, −0.6)	−1.4 (−2.2, −0.6)	−2.5 (−3.1, −1.9)	−0.8 (−1.7, 0.2)	0.3 (0.2, 0.3)	1.4 (1.1, 1.7)
Percentage of women aged 20–24 years first cohabiting after age 18 years	−0.1 (−0.2, 0)	−2.5 (−3.5, −1.4)	−1.7 (−2.0, −1.3)	−0.5 (−1.3, 0.3)	−0.2 (−0.4, −0.1)	−3 (−4.3, −1.8)	0.1 (0, 0.2)	1.6 (1.3, 1.9)
Mean sex ratio at birth for children born in the last five years (females per 1,000 males)	0 (−0.1, 0)	−2.5 (−3.5, −1.6)	0 (0, 0)	−2.2 (−3.0, −1.4)	0 (−0.1, 0.1)	−3.2 (−4.3, −2.2)	0 (0, 0.1)	1.7 (1.4, 2)
Percentage of population living in households that use an improved sanitation facility	−6.5 (−7.2, −5.7)	3.9 (2.8, 5.0)	−2.9 (−3.5, −2.3)	0.8 (−0.2, 1.7)	−8.2 (−9.1, −7.2)	4.9 (3.8, 6.0)	0.9 (0.7, 1.1)	0.8 (0.4, 1.1)
Percentage of population living in households with an improved drinking-water source	−0.1 (−0.2, 0.1)	−2.5 (−3.5, −1.5)	−0.2 (−0.3, 0)	−2 (−2.8, −1.2)	−0.1 (−0.3, 0.1)	−3.2 (−4.3, −2.0)	0.0 (−0.1, 0.0)	1.7 (1.4, 2.0)
Percentage of population living in households with electricity	−5.2 (−6.3, −4.2)	2.7 (1.6, 3.8)	−1 (−1.6, −0.5)	−1.2 (−2.2, −0.1)	−4.4 (−5.5, −3.4)	1.2 (−0.2, 2.5)	0.3 (0.1, 0.5)	1.4 (1.0, 1.8)
Percentage of households using clean fuel for cooking	−3.1 (−3.8, −2.5)	0.6 (−0.3, 1.5)	−0.9 (−1.2, −0.6)	−1.3 (−2.0, −0.5)	−3.2 (−3.9, −2.6)	−0.1 (−1.1, 1.0)	0.4 (0.3, 0.5)	1.3 (1.0, 1.6)
Percentage of households with any usual member covered under a health insurance or financing scheme	−1.4 (−1.8, −1.0)	−1.1 (−2.2, −0.1)	0 (−0.2, 0.2)	−2.2 (−3.0, −1.3)	−0.8 (−1.3, −0.4)	−2.4 (−3.5, −1.4)	0 (−0.1, 0.1)	1.7 (1.3, 2.0)

Abbreviations: CI, confidence interval; NFHS, National Family Health Survey; PP, percentage points, SD, standard deviation.
↵^aChild stunting was defined as height-for-age < −2SD. Child wasting was defined as weight-for-height < −2SD. Child underweight was defined as weight-for-age < −SD. Child overweight was defined as weight-for-height > 2SD. All values are coefficient (bootstrapped 95% confidence interval).
↵^bDifference between observed and expected change between 2016 (NFHS-4) and 2021 (NFHS-5). Contributions are modelled through 2-way Blinder-Oaxaca decomposition with each indicator entered separately. Equal weights (w=0.5) were applied for both survey rounds. The decomposition model gives each of the 640 districts analyzed equal weight, and district grand mean will not sum to the state population-weighted mean.