86 per cent of districts show more than 60 per cent diet diversity failure: NFHS 5

Gaurav Gunnal, International Institute for Population Sciences (IIPS), Mumbai and Dhruvi Bagaria, Indian Institute of Public Health Gandhinagar (IIPHG) stresses that in 2019-21, according to NFHS 5, stunting has reduced from 38.4 per cent to 35.5 per cent in the country, wasting has reduced from 21.0 per cent to 19.3 per cent and underweight prevalence has reduced from 35.8 per cent to 32.1 per cent. Even with these slight improvements, India is set to miss its SDG targets for all malnutrition related indicators

“Zero Hunger” is the second United Nations’ Sustainable Development Goals (SDGs). It aims to ‘End hunger, achieve food security, improve nutrition, and promote sustainable agriculture by the year 2030’ globally. According to global figures, in 2019, 144 million children under the age of 5 were stunted (low height for age), and 47 million were affected by wasting (low weight for height). Specifically, 74.5 million children under 5 years of age were stunted and 31.5 million were wasted in Asia and Pacific region. A large proportion of these children live in South Asia (Elbehri & Schumacher, 2021). Taking a closer look at the data, it can be observed that the South Asian countries have made some progress. Stunting rates have declined in most of the countries with the exception of Pakistan during 2000-15. Though the rate of wasting has decreased in the neighbouring countries, it has slightly increased in India (7.6 per cent points) and Bangladesh (11.8 per cent points) (Sharma, 2020). In 2019-21, according to NFHS 5, stunting has reduced from 38.4 per cent to 35.5 per cent in the country, wasting has reduced from 21.0 per cent to 19.3 per cent and underweight prevalence has reduced from 35.8 per cent to 32.1 per cent. Even with these slight improvements, India is set to miss its SDG targets for all malnutrition related indicators.

Nutrition has a multidirectional relationship with many developmental factors. Good nutrition is essential for growth and development of a child especially in the first 2 years of life. A growing child requires varied essential vitamins, minerals and other nutrients. Hence, it is recommended that a child should be exclusively breastfed till 6 months of age and a diverse diet in the form of age-appropriate complementary feeding should be introduced. Lack of exclusive breastfeeding, pre-lacteal feed, delayed or incorrect complementary feeding practices are the leading causes of stunting globally. These factors also lead to other types of malnutrition. Such children are at an increased risk of poor brain development, weak learning, low immunity, increased infections and mortality1 . Every second child death can be attributed to undernutrition (De & Chattopadhyay, 2019). Hunger and malnutrition since early life means less productive individuals, who are more prone to disease and thus often unable to earn more and improve their livelihoods. Thus, perpetuating inter-generational malnutrition cycle.

Dietary diversity is an important indicator of food consumption, and highlights the extent to which households have access to different food groups (Jain et al., 2022). An indicator called Minimum Dietary Diversity score (MDD) has been recommended by WHO to assess the diet quality consumed by children between 6-23 months of age. According to this score, the children should be given at least 5 of the following 8 food groups; these include breast milk, grains roots and tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin rich fruits and vegetables; other fruits and vegetables. Inclusion of at least 5 of these groups ensures that the child receives all the essential micronutrients required for their growth (Working Group on Infant and Young Child Feeding Indicators, 2006). While diet diversity is crucial, meal frequency is also an important component of feeding practices to ensure essential quantity of nutrients have been consumed by the child. 

Minimum Diet Diversity Failure (MDDF) is defined as consumption of less than five food groups out of eight groups. Anthropometric measures (weight, height) cannot reveal all forms of malnutrition such as vitamin deficiencies (anemia, vitamin A deficiency, etc.). Hence, these indicators may on their own not show a clear picture of nutritional status of a community (Jain et al., 2022).

Changes in the prevalence of MDDF from NFHS 3 (2005-06) to NFHS 5 (2019-21) has been portrayed in the figure above. A 10.35 per cent decrease can be observed in MDDF from NFHS 3 to NFHS 5. At a closer examination, a 6.87 per cent decrease is observed from NFHS 3 to NFHS 4 but NFHS 4 to NFHS 5 saw a smaller decrease of 3.45 per cent. This can possibly be attributed to the COVID-19 pandemic. Food security worldwide had been severely impaired due to disruptions to food production and supply chains; loss of income and livelihoods; widening of inequality; disruptions to social protection programmes such as ICDS, TPDS; and uneven food prices in localised contexts (Committee on World Food Security High Level Panel of Experts on Food Security and Nutrition, 2020).

Regional analysis shows that central India (84.56 per cent) has the highest proportion of MDDF in the country while the eastern part (70.38 per cent) of the country has the lowest share as per NFHS 5. The state of Uttar Pradesh recorded the highest prevalence of MDDF at 86.09 per cent followed by Rajasthan at 85.1 per cent and Gujarat at 83.96 per cent. Lowest MDDF was observed in Sikkim (42.63 per cent), Meghalaya (46.48 per cent) and West Bengal (50.36 per cent).

Figure 2: MDDF prevalence across districts of India according to NFHS 5

The district level prevalence is presented in figure 2. The lowest prevalence was recorded in East Garo hills district (26.58 per cent) Meghalaya; Purba Bardhaman district (31.12 per cent), West Bengal and Mahe district (33.06 per cent), Puducherry while the highest MDDF was observed in Datia, Madhya Pradesh (95.33 per cent), Sindhudurg, Maharashtra (95.09 per cent) and Palghar, Maharashtra (94.79 per cent). Approximately 86 per cent of the districts in the country have MDDF prevalence of 60 per cent or more. This is a concerning finding for the future of the country.

To address the issue of poor nutrition in the country, Government of India has launched a flagship scheme called Poshan Abhiyan (Prime Minister’s Overarching Scheme for Holistic Nutrition) in 2018. Every year the month of September is celebrated as Poshan Maah to put concentrated effort into raising community awareness and boost people’s participation in health and nutrition related decisions. This year activities such as sensitisation drives, outreach programmes, growth monitoring drives to identify malnourished children at Anganwadi centers and health camps, among others were adopted. Poshan Panchayat was an innovative component added wherein community meetings were conducted by field level workers (FLWs) such as ASHAs, Anganwadi Workers, ANMs. Here, discussions on issues such as diverse food groups, IYCF practices, etc. were to be conducted to initiate conversation about health and nutrition for pregnant and lactating women, children below six years of age and adolescent girls. Poshan Vatikas, Amma ki Rasoi, etc. are other efforts to encourage a varied and balanced diet at the community level. Such and many more concerted efforts are required to address the issue of malnutrition in the country.

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