Underweight Prevalence Falls, But India Grapples With Obesity, Micronutrient Deficiency

In addition, India has to challenge growing obesity--districts where more than 5% of children were overweight or obese increased from 93 to 223 in the same period, the report by the International Food Policy Research Institute (IFPRI) found. Further, more children (67%) were anaemic in 2019-21 than in 2015-16 (59%), data from the fifth National Family Health Survey (NFHS 5) show.

Taken together, “the triple burden of malnutrition--undernutrition, hidden hunger and overweight--threatens the survival, growth and development of children and young people”, UNICEF says.

Due to these challenges, India is off track to meet the Sustainable Development Goal (SDG) of ending child malnutrition in all its forms by 2025, part of the goal to ‘End hunger, achieve food security and improved nutrition and promote sustainable agriculture’. The goal includes reducing stunting by 40%, reducing the proportion of wasted children by 5% compared to 2012, and no increase in overweight children from 2012.

Experts point to a lack of diet diversity, unregulated and aggressive marketing of packaged foods, along with socioeconomic factors and a lack of a multi-sectoral approach from the government to tackle nutrition-related issues.

Fewer children are now underweight

The proportion of underweight children decreased in 21 of 36 states, while it increased in 11 states, and remained unchanged (less than one percentage point change) in five states, shows a comparison of data from the NFHS 5 in 2019-21 and NFHS 4 in 2015-16.

Stunting--low height for age--among children under the age of five years declined from 38.4% to 35.5%. Districts with a high level of stunting, that is with over 40% of children short for their age, reduced from 217 to 161 between 2015-16 and 2019-21.

Health and nutrition interventions, household assets and improved sanitation, along with maternal education, a higher age at marriage, community-level hygiene and electrification helped reduce the underweight and stunted child population, as per a June 2020 paper by IFPRI that studied Chhattisgarh, Gujarat and Odisha.

However, some experts believe that India could have reversed some of this progress as routine health services were disrupted during Covid-19. "It's important to acknowledge that the numbers showing improvement may have changed due to the impact of Covid,” says Poornima Nair, director of health and disability at Apnalaya, an NGO working with the urban poor for better access to basic services such as health and education. “References, including Lancet, have highlighted the high probability of increased acute malnutrition resulting from food and nutrition insecurity during the Covid period.”

Increase in overweight children

NFHS-5 defines overweight as excess body weight relative to height for children. The proportion of overweight children has increased in the majority of states and the number of districts that have recorded high levels (more than 5%) of childhood obesity have increased from 93 districts to 224 from 2015-16 to 2019-21.

In 2019-21, 3.4% of Indian children were overweight, an increase from 2.1% in 2015-16. Between 2015-16 and 2019-21, in 33 states, the proportion of overweight children increased, while it decreased in three states, and remained about the same in eight states.

Hidden hunger

Hidden hunger is a form of undernourishment characterised by deficiencies in vital micronutrients like vitamins and minerals, leading to diseases such as anaemia, night blindness, rickets and scurvy.

As many as 67% of children aged between six months and five years had anaemia in 2019-21--measured as haemoglobin levels below 11.0 g/dl--which is higher than the NFHS-4 estimate of 59% in 2015-16.

The NFHS does not measure other nutrient deficiencies, but data from the 2019 Comprehensive National Nutrition Survey of children (CNNSC) show that 19% of pre-school children and 32% of adolescents had a zinc deficiency, while 23% of preschool children and 37% of adolescents had a folate deficiency. Vitamin B12, vitamin A and vitamin D deficiencies range between 14 and 31% for pre-school children and adolescents.

In India, hidden hunger remains a significant concern, with high rates of anaemia, resulting in fatigue and reduced productivity, as per a 2019 book, Transforming Food Systems for a Rising India, by the Tata-Cornell Institute for Agriculture and Nutrition. Additionally, essential nutrients such as iodine and vitamin A have not been adequately integrated into the Indian diet.

Even in overweight or obese individuals, hidden hunger in the form of micronutrient deficiencies is possible. It is a misconception that being overweight guarantees good health, says Dipanshi Sharma, manager for health and nutrition at Microsave Consulting, a Delhi-based consulting firm working on financial and social inclusion.

Emphasising the need to consider nutrition insecurity, practitioners must broaden their focus beyond just iron deficiency, and acknowledge the impact of different micronutrients on overall nutritional health, Nair said.

Lack of diet diversity

Research suggests that the prevalence of obesity and non-communicable diseases in India is associated with a high consumption of carbohydrates and sugar. Policies, such as India’s Public Distribution System (PDS) for food, which distributes staple grains, such as wheat and rice, and sugar, at low prices may contribute to overconsumption, the 2019 book suggests, adding that an increased intake of sugar and fat products, as well as refined cereals, is linked to a rise in obesity and diabetes incidence, especially with sedentary lifestyles and abdominal obesity (belly fat).

A lack of diet diversity (taken as consuming more vegetables, dairy, energy, protein and calcium, while also consuming less refined grains and carbohydrates) is linked to a higher risk of obesity, according to a 2011 study of Iranian children by the University of Isfahan. Dietary diversity of households is known to be correlated with better nutrition, according to a 2002 IFPRI discussion paper.

The mid-day meal scheme for school children is an important intervention for better child nutrition, as studies show that it effectively reduces undernutrition in school-aged children, particularly among families affected by shocks like droughts, as per the 2019 book. Similarly, universal access to PDS for foodgrains was associated with increased household diet diversity, according to a 2016 study by the Indian Institute for Human Settlements (IIHS) in Odisha.

Mid-day meals in India’s schools, as well as the take-home rations given as part of India’s Integrated Child Development Services programme for women and children, include distributing sugary items such as soya-based energy biscuits, cornflakes in Nagaland and Meetha Daliya (sweet porridge) in Uttar Pradesh, said Purnima Menon, senior research fellow at IFPRI. “Therefore, we need to seriously address the nutritional quality of the foods offered in public programmes.”

“Consider incorporating locally available food grains like pulses into the PDS to diversify mid-day meals,” says Nair. She suggests moving away from the mix of rice, potato and pulses (khichdi) that is served often, and instead including regional fruits and vegetables into the school meal. “Successful examples include introducing eggs in some states, aligning with local diets. A campaign promoting nutritious millets also shows promise.”

Improving diet affordability is also important, as limited income and employment opportunities can lead to higher income insecurity, increasing malnutrition risk, while higher income security and better market access are associated with greater dietary diversity and lower levels of undernutrition in more developed Indian states, as per the book by the Tata-Cornell Institute for Agriculture and Nutrition.

As much as 45-64% of the rural population of India in 2011 could not afford the diet recommended under the National Institute of Nutrition’s 2011 Dietary Guidelines for Indians, found a 2020 study by IFPRI. The study used 2011 data as there are no recent data available from the National Sample Survey Office.

“Across the board, it's evident that improved high-quality diets are essential to combat all types of malnutrition… Regardless of any other actions taken, a key step is to make healthier diets more affordable and accessible to a wider audience," says Menon.

Gender roles are also important, with women often burdened with domestic tasks, making them more susceptible to marketing tactics promoting convenient packaged foods. "We found fascinating survey results on gender roles in multiple districts. Women actively participate in farming and markets in South Asian countries, but they shoulder domestic tasks alone, allowing companies to target them with quick and easy, but unhealthy, products. This highlights the need for societal reorientation on family meals and responsibility for ensuring healthy, nutritious food consistently," says Menon.

Easy availability of packaged foods

The availability and aggressive marketing of unhealthy packaged foods have led to significant shifts in diets, making it easier for consumers to opt for these products, while the prices of essential nutritious foods like lentils, vegetables and fruits have soared, experts told IndiaSpend.

“There are now local companies that are offering packaged food at affordable prices…Moreover there is the marketing of these products with their attractive colours and the spread of media which makes the products a household name,” says Sharma of Microsave Consulting.

Experts say lack of effective regulations in the packaged food industry, including marketing practices, labelling, and public awareness efforts, raises concerns about their impact on public health.

Successful strategies implemented in other countries such as Mexico and Chile, to reduce the consumption of packaged food, include labelling laws to reduce sugar-sweetened beverage consumption.

Currently, India has no front-of-package labelling system. But the Food Safety and Standards Authority of India (FSSAI) in September 2022 developed a star rating system for labelling, a draft of which has been shared with stakeholders and the general public for their feedback. The new system proposes scores be assigned based on energy values, saturated fat, sugar, sodium, fruit, vegetables, nuts, legumes, millets, dietary fibre and protein per 100 gm servings of solid and liquid foods. Called the India Nutrition Rating (INR) system, it suggests a rating from 1/2 or half a star (least healthy) to 5 stars (healthiest) for packaged food. This approach is a combination of a health star rating (also used in Australia and New Zealand) and a nutri-score approach, experts say.

“INR's advantage lies in its readable front-of-pack labels, akin to the familiar 5-star rating in electronics. Yet, its voluntary nature [the rule is not yet enforced] and method of calculating can be manipulated. High sugar and fat, balanced by nuts and fruits, pose questions about true health assessment,” said Sharma. “There is a recommendation that producers should also furnish the percentage of salt, sugar and fat along with the rating.”

“The effectiveness of positive messaging, such as nutri scores and health star rating, in curbing the consumption of unhealthy foods remains questionable. Addressing these issues within the food system and imposing stricter regulations on industries producing unhealthy foods are crucial areas that require attention," says Menon.

Open spaces for exercise, link with other diseases

Data show that more children in urban India, and more children born in wealthier families are overweight. In urban India, 4.2% of children were overweight compared to 3.1% in rural India. In the highest income group, 4.8% of children were overweight compared to 2.7% in the lowest quintile.

Other factors responsible for the rise in obesity, Nair says, are sedentary lifestyle, prevalent across various social classes, not just limited to the middle and upper-middle classes. Nair emphasises the importance of providing open spaces for growing children to ensure their overall well-being.

Further, studies show a link between obesity and diseases like diabetes and hypertension, but the policy to prevent and combat these remains fragmented in India. “There is a need for operationalising a multi-sectoral approach involving collaboration between multiple agencies. This is not a new recognition but in India, in 2017, the national action plan to tackle noncommunicable diseases--obesity included--recommended coordination amongst 17 ministries,” says Chandrakant Lahariya, a practising physician and public health specialist, whose work focus on prevention and treatment of lifestyle diseases. “Tackling obesity requires municipal corporations, the Ministry of Urban Development, and the Ministry of Health to find comprehensive solutions for addressing obesity and related challenges effectively.”

IndiaSpend has reached out to the offices of India’s health minister Mansukh Mandaviya, his personal secretary Arohiben Patel, additional personal secretary Anil Radiya, Additional Commissioner of Child Health Sumita Ghosh, and other officials for their comments on the triple burden of malnutrition in India. The story will be updated when we receive a response.

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