Investing in nutrition over the entire lifespan to overcome the challenge of intergenerational cycle of undernutrition should be the end goal
For India, the Intergenerational Cycle of Undernutrition has been a cause for concern. High incidence of child marriage and teenage pregnancies have been the major reasons for child undernutrition, with long term impact on health, education, and employment. Investment in maternal and child health and adolescent well-being yields a high cost to benefit ratio, with a triple dividend in both low- and upper-middle income countries.
Looking at the National Family Health Survey (NFHS) 5 data, there is a stagnation in early marriage but a rise in teenage pregnancies, leading to complications at birth, including low birth weight and higher mortality rates. The North Eastern states of Tripura and Assam show alarmingly high prevalence of teenage pregnancies and child marriage, more than the national average (fig 1). Data indicates a rise in prevalence of teenage pregnancies and child marriage since NFHS-4 (2015-16).
Figure 1: Prevalence of teenage pregnancies and child marriage (before age 18 years) in North Eastern States of India (NFHS-5)
Of concern is Tripura, which shows a steep incline in both child marriage (33.1 percent in 2015-16 to 40.1 percent in 2019-21), and teenage pregnancies (18.8 percent in 2015-16 to 21.9 percent in 2019-21). Other than Tripura, Assam, Manipur, and Meghalaya show higher prevalence in teenage pregnancies as to the national average.
Stunting rates in children under the age of five are alarming for Meghalaya at 46.5 percent, the highest in the region and nation wide (fig 2). The NFHS-5 shows a sharp rise in stunting for Tripura, which is a cause for concern. Also alarming are Manipur, Sikkim, and Assam in the category of high-level stunting (30-< 40 percent) with more than half the districts presenting a public health concern. Wasting also showed a significant incline in the states of Nagaland, Manipur, Mizoram, and Assam as compared to 2015-16. Assam, with a prevalence of 21.7 percent, was higher than the national average at 19.3 percent; Nagaland (19.1 percent) showed a steep incline (7.8 percentage points) from NFHS-4 and was second highest; followed by Tripura at 18.2 percent. Rates of underweight children in the North-Eastern states also showed worrying trends. Four of the eight states showed an increase in the prevalence of being underweight, with Assam being the highest at 32.8 percent and Manipur the lowest at 12.7 percent. Nagaland showed a 10.2 percent increase in underweight children, from 16.7 percent in 2015-16 to 26.9 percent in 2019-21. Mizoram and Sikkim are at the lowest at 12.3 percent and 12.4 percent respectively. Aong with malnutrition, seven out of eight North-Eastern states, except for Meghalaya, show an increasing trend in overweight prevalence in children under five. Sikkim, which recorded a decrease of over 3 percent in underweight children, showed a 1 percent increase in the percentage of overweight obese children. Overall, the North-Eastern states show a higher prevalence of children under-5 years who are overweight as compared to the national average of 2.1 percent. Figure 2: Malnutrition trends across North Eastern States of India (NFHS-5)
The data on nutritional status of women, on the other hand, indicates a decline in percentage of women who are thin (BMI less than 18.5) from 22.9 percent in 2015-16 to 18.3 percent in 2019-21, and a sharp incline in women who are obese/overweight from 20 percent to 24 percent in the same time period. The percentage of anaemic women in the age group of 15-45 years increased from 53 percent to 57 percent.
Evidence indicates that children born to adolescent mothers have a 10 percent higher prevalence for stunting. Poverty and gender discrimation further heighten the intergenerational cycle of undernutrition impacting cognitive and physical development. This calls for robust interventions for both the mother and child, to address the high burden of undernutrition.
Data on anaemia in children under five, adolescent girls (15-19 years), and women (15-49 years) indicates a rise in anaemia in both children and women. Anaemia in children under five has increased in all states except Meghalaya. Assam is the highest at 68.4 percent (32.7 percentage point increase from 2015-16), followed by Mizoram at 46.4 percent (27.1 percentage point increase from 2015-16), Manipur at 42.8 percent (18.9 percentage point increase from 2015-16), and Tripura at 64.3 percent (a 16-percentage point increase from 2015-16). Anaemia in women of reproductive age (15-49 years) shows an incline in Assam at 65.9 percent, that is higher than national average of 57 percent. Looking at trends for anaemia in adolescent girls (15-19 years), a sharp rise can be observed in Assam at 67 percent (24.3 percentage points increase), and Tripura at 67.9 percent (15.3 percentage points increase). Anaemia in adolescent mothers has a lasting impact, posing the risk of maternal mortality, low birth weight, and higher risk of anaemia in the newborn.
Factors including mother’s education and order of birth have shown to influence the consumption of IFA among pregnant women.
Data for nutrition specific intervention in Assam is a cause for concern. The Comprehensive National Nutrition Survey, shows 40 percent adolescent girls suffering from anaemia. About 25 percent of adolescent girls are deprived of services like mid-day meal, bi-annual health checkup and deworming, and weekly iron and folic acid supplementation. NFHS-5 data indicates a wide variation on consumption of iron and folic acid (IFA) supplementation for 180 days by pregnant women in North Eastern states, with Sikkim at 31.5 percent and Nagaland at 4.1 percent. Factors including mother’s education and order of birth have shown to influence the consumption of IFA among pregnant women.
Talking of indicators on infant and young child-feeding practices, exclusive breastfeeding rates witnessed a decline in six of the eight states, with Sikkim being the lowest at 28.3 percent. Early initiation of breastfeeding has improved across states, with Meghalaya having highest prevalence at 78.8 percent. Only two states, Sikkim (33 percent) and Tripura (36.2 percent) showed lower prevalence than the national average (41.8 percent). The practice of timely introduction of semi-solid food to a child was highest in Manipur at 78.9 percent, however, Tripura showed an increase of 39.5 percentage points, from 13.6 percent to 53.1 percent in 2015-16 to 2019-21 respectively. Minimum acceptable diet (or diet adequacy) shows a wide range of percentage coverage noted at a range of 8 percent to 29.8 percent in Assam and Meghalaya respectively.
Successful stories of change across India suggest investment in girls and women and heightened delivery of health and nutrition interventions in bringing down malnutrition.
The nutrition sensitive indicators on water and sanitation show marked improvement across Manipur, Mizoram, and Sikkim. It is worthy to note that provision of clean drinking water in Mizoram is at par with the national average of 95.9 percent, and is higher than the national average on improved sanitation (95.3 percent) and households using clean fuel for cooking (83.8 percent). Attending antenatal care (ANC) clinic can help overcome adverse health outcomes during pegnancy and childbirth. Only four out of eight states namely Assam, Manipur, Meghalaya, and Nagaland show an increase in ANC services availed by pregnant women as compared to NFHS-4. Manipur shows the highest coverage in women availing ANC services at 79.4 percent.
Successful stories of change across India suggest investment in girls and women and heightened delivery of health and nutrition interventions in bringing down malnutrition. A review suggests investing in nutrition over the entire lifespan to overcome the challenge of intergenerational cycle of undernutrition. Improved nutrition across the life cycle is required for improved growth and development. The Mission Poshan 2.0 aims to contribute to human development by addressing the challenges of malnutrition in children, adolescent girls, and women through a inter-ministerial convergance and effective communication strategies. This calls for monitoring and implementation, and time to act is now.
The views expressed above belong to the author(s).