The document presents insights from the National Family Health Survey in India, highlighting trends in child nutrition, including stunting, wasting, and anemia. It reveals modest improvements in child height and significant challenges regarding undernutrition, as well as the effects of socioeconomic factors on these outcomes. The analysis underscores the importance of multi-sectoral investments in health services, sanitation, and maternal education to combat malnutrition in India.

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Strengthening Actions for Nutrition in India: Insights from the
National Family Health Survey
Sept 4, 2018; India International Centre, New Delhi, INDIA
Childhood stunting and wasting in India: Trends and distribution
Chair: Purnima Menon
Changes in child heights and determinants of child heights in India
Dean Spears & Diane Coffey
An analysis of child height-for-age using the newly released data from the National Family
Health Survey-4 indicates that the average child height increased by about four-tenths of a
height-for-age standard deviation between 2005 and 2015. Although important, this
increase is small relative to India’s overall height deficit, and relative to economic progress;
children in India remain among the shortest in the world. It is unsurprising that the increase
in height-for-age has been modest because none of the principal factors responsible for
India’s poor child height outcomes have substantially improved over the last decade.
Familiar patterns of regional, sex, and caste disadvantage are reflected in child height in
2015.
Factors contributing to stunting declines in India (2006-2016)
Phuong Nguyen, IFPRI
India contains one third of the world’s stunted children and has long been criticized for
making slow progress in combating undernutrition. We combine data from two rounds of
National Family Health Surveys to examine determinants that may explained changes in
stunting between 2006-2016 among children under 5 years of age. Our analyses suggested
several determinants that contributed to stunting reduction in the last decade, including
improvement in household social economic status, health services access, sanitation,
maternal schooling, and maternal nutritional status. Our findings confirm the multi-sectoral
nature of stunting, and call for special investments in sanitation, health services and
women’s human capital to further accelerate progress against stunting.
Has wasting increased in India? Seasonality in wasting between 2006 and 2016
Robert Johnston, UNICEF
The Indian NFHS surveys showed an increase in the prevalence of wasting from 19.8% to
21.0% between 2006 and 2016. This paper analyses the effect of seasonality by date of data
collection on influencing this trend of wasting. The prevalence of wasting (WHZ<-2SD) and
WH Z-scores were computed for NFHS 3 and NFHS 4 data by day month and year of
interview and compared across the national and state level. Data were analyzed using
descriptive statistics and multivariate regression methods to identify the seasonal pattern of
data collection. The analysis of seasonal trends of wasting control for socio-demographic
differences and timing of data collection across states. The prevalence of wasting between
2006 and 2016 showed a statistically significant increase. Seasonality may explain

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differences. When data from repeat surveys are collected in the same month, a non-
seasonally biased estimated can be calculated. When comparing wasting data across surveys
with differing periods of data collection, results should control for seasonality to prevent
confounding with the interpretation of results.
Prevalence of severe acute malnutrition among infants less than 6 months of age in India
and associated risk factors
Tarun Shankar Choudhary, SAS
There is a paucity of data on the incidence, prevalence and covariates of SAM in infants less
than six months of age in developing countries. The current analysis uses the NFHS 4 data to
document the prevalence of SAM in infants less than 6 months of age and examine the
association of early SAM with household, maternal and child related factors. The main
findings in this secondary analysis reveal a very high SAM prevalence of 14.8% in the first six
months of life. Factors independently associated with SAM in young infants included low
birth weight, younger infant age within the six-month window and non-utilization of
nutritional supplements by the mother during lactation from ICDS.
Other nutrition outcomes: Digging deeper into trends and distribution
Chair: Shweta Khandelwal
Anemia in one million Indian women and children: Trends and drivers of change from
2006 to 2016
Samuel Scott, IFPRI
India carries the largest burden of anemia globally. Identification of the factors that
contribute to anemia reductions is needed to accelerate anemia reduction. Using NFHS3 and
NFHS4, we identified drivers of Hb and anemia using multivariate regression and estimated
their contribution to changes in these outcomes over time using regression-based
decomposition. Hb and anemia improved significantly between 2006-2016 in children
(4.5g/L and 11 percentage points [pp], respectively) and PW (3.2g/L and 7.6pp), but not in
NPW. Despite these changes, anemia is still very high (>50%) and progress varied
considerably by state (-33pp to +16pp). The key drivers of anemia reduction were maternal
schooling, coverage of NHIs, socioeconomic status, sanitation, and meat and fish
consumption.
Trends in Triple Burden of Nutrition and its Associated Factors in India
Tejal Lakhan, IIPS
The phrase “triple burden of nutrition” refers to the co-existence of under-nutrition,
Overnutrition and micronutrient deficiencies. Among children, increase has been found in
the percentage of children with no nutritional problem signifying improvements in the
nutritional condition of children. But an opposite scenario has been observed among women
with significant increase in the triple burden of nutrition. Factors associated with Triple
Burden of Nutrition among children are related with nutritional status of mothers
documenting transgenerational impact of maternal under and over-nutrition on the
offspring. Among women dietary and lifestyle habits along with socio economic status are

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playing a major role. Currently over-nutrition rates are relatively low among children but
increasing trend suggests prevention, early detection and effective management of obesity.
Overweight and Obesity among Children in India: Trends & Association with Commercial
Baby Food Consumption
Shreyans Rai, IIPS
Child’s health status in early days of their life has a lot of impact on their growth and other
functioning. The primary objective is to examine the association of consumption of baby-
food on obesity among children (6 to 23 months). The study attempts to look for several risk
factors using statistical techniques. Logistic Regression shows a positive association (Odds
1.3) of commercial baby-food like ceralac on obesity among younger children. Also findings
from an advanced statistical technique i.e. Propensity Score shows that on an average, there
is 10 percent more probability of being overweight or obese for children consuming baby-
food. This finding supports that the increased intake of commercial baby-food in childhood
can lead to overweight or obesity amongst them.
Adolescent nutritional status in India: Insights from the NFHS-4
Sowmya Ramesh, Population Council
Nutrition is one of the key factor that influences changes in adolescents that may have
consequences over the life-course. The current study assessed the nutrition status of
adolescents aged 15-19 years, factors associated with malnutrition and identified priority
geographies having vulnerability to malnutrition. Data for this study were drawn from NFHS-
4 and Census 2011. Regression models and latent-class-analysis were run to estimate odds-
ratios and to classify sample into different diet-mixing groups. Further, vulnerability scores
were derived to categorize states and districts into having high, moderate and low
vulnerability. Half of the girls and nearly 30% of boys were anaemic. Over 40% of
adolescents were underweight. Adolescents with no education, belonging to SC/ST
households, and poor families had higher odds of malnutrition. Gender difference was also
significant in terms of food consumption. Seven states and 198 districts have high
vulnerability to malnutrition. The results indicate gender and geography specific intensive
intervention to augment existing efforts to reduce malnutrition among adolescents in India.
Immediate and underlying determinants of nutrition outcomes in India
Chair: Rajan Sankar
Infant and young child feeding
Progress and inequalities in infant and young child feeding practices in India between
2006-2016
Rasmi Avula (IFPRI)
This study examines the relationship between socio-economic status (SES) inequalities,
intermediate determinants and trends and changes in inequalities for infant and young child
feeding (IYCF) practices in India, over 2006-2016. It also identifies factors that may explain
the differences in IYCF across SES groups. The findings highlight significant improvements in

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breastfeeding practices and closing of equity gaps in exclusive breastfeeding. Although the
equity gaps in complementary feeding practices also narrowed, complementary feeding
shows slow progress and poor practices across all segments of society. These results call for
special efforts to further improve breastfeeding, and concerted actions to address all aspects
of complementary feeding across SES quintiles.
Socio-Economic Patterning of Food Consumption and Dietary Diversity among Indian
Children
Sutapa Agrawal, Tata Trusts
We assessed the pattern in food consumption and dietary diversity by socioeconomic status
(SES) among Indian children using the most recent nationally representative cross-sectional
data from the National Family Health Survey (NFHS-4/2015-16). The key findings were that:
(1) Overall, the mean dietary diversity score was low (2.10;95%CI:2.08-2.13) and the
prevalence of inadequate dietary diversity was high (79%); (2) Both household wealth
(OR:1.48) and maternal education (OR:1.46) were significantly associated with adequately
diversified dietary intake, but the SES gradient was not particularly strong compared to the
magnitude seen for anthropometric failures in prior studies; (3) The associations between
SES and consumption of individual food items and food groups were less consistent. We
conclude that interventions designed to improve food consumption and diversified dietary
intake among Indian children need to be more universal in their targeting given the overall
high prevalence of inadequate dietary diversity and the relatively small differentials by SES.
Gender & Poverty
Intra-household gender discrimination and childhood under-nutrition and preventive and
curative care seeking for children
Priyanka Dixit, Tata Institute of Social Sciences
This paper examines sibling composition on gender discrimination in childhood nutrition,
anemia and treatment seeking behavior using National Family Health Survey-4, India (2015-
16). Unadjusted and adjusted binary logistic regression models were used for four health
outcome variables stunting, wasting, underweight, and anemia, and three treatment seeking
behavior variables namely fever, diarrhea and ARI. Analysis has been conducted in one, two
and three children families in India and its six regions. India and central region findings show
gender bias against daughter in curative care even in one child families. However, gender
bias relating to anemia and nutrition indicate no discrimination of female children regardless
of sibling composition. Narrowing gender gaps suggest that parents invest equally and
ensure equality in nutrition and healthcare distribution for sons and daughters, likely
reflecting some weakening of strong son preference.
The mediating role of un-intendedness of births on the effects of the preceding birth
spacing and family size on childhood stunting
Md. Juel Rana, Jawaharlal Nehru University
This study assesses the mediating role of unintendedness of births of the effects of the
preceding birth spacing and family size on the childhood stunting in India. The summary of
findings suggests that the risk of childhood stunting has a significant positive relationship

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with the decreasing preceding birth spacing and increasing family size. In other words, the
children of unintended births do not significantly mediate the role of preceding birth spacing
and family size respectively in reducing the childhood stunting. Moreover, the preceding
birth spacing has greater effects on childhood stunting in India than the family size. About
3% of child stunting can be reduced if all the baby born with a gap of at least three years.
Intergenerational transmission of deprivation and childhood stunting; the relationship
between both father’s and mother’s stature and stunting in under-5 children
Amrita Gupta, Tata Institute of Social Sciences
Short paternal height is associated with a higher risk of stunting among offspring. The study
examines the linkages between parental height and child stunting in India using NFHS-4
data. Parental height was categorized as short and normal height. With the increase in the
height of the parents, the prevalence of child stunting decreased. The highest prevalence of
stunting was observed among children with both parents of short height while it was lowest
when both the parents were of normal height. Parental education and economic status of
the households emerged as the major predictors of stunting among children with short
height parents suggesting that the intergenerational transmission of short height can be
offset through an improvement in education and economic status.
Do height of population and level of poverty differ in agro-climate zones of India?
Sayeed Unisa, IIPS
Adult height is a potential tool which reflects the state of a nation’s nutritional status of its
citizens. In this study, an attempt is made to examine the height of children and adult by
agro-climatic regions of India as classified by Khanna (1989). Around 5cm difference in
height for male as well as for females are found in the regions. Among rich and poor class
within the region, around 1.5 to 3.5 cm difference is found in height of adults. The
percentage poor also varies from 7 to 65% in these regions. After controlling for wealth, and
socio-economic groups, still the differences among the regions are significant, and this may
be due to the availability of food and food habits.
What insights do the NFHS-4 data offer on reach, scale and equity of
nutrition-focused interventions in India’s policy framework?
Chair: Niranjan Saggurti, Population Council
Has India’s Integrated Child Development Services finally turned the corner? An analysis
of program coverage, equity and socio-demographic determinants of utilization between
2006 and 2016
Kalyani Raghunathan (IFPRI)
Evidence on factors affecting the scale-up and coverage of large-scale nutrition programs is
limited. India’s ICDS program was reformed in 2006-2008 with mandated universalization,
additional financing and implementation. We examine equity in program expansion and
determinants of utilization using data from two rounds of nationally representative surveys
in 2006 and 2016. ICDS utilization increased dramatically from 2006 to 2016, with
considerable variation at the sub-national level. Although overall utilization has improved,

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the poor are still left behind, with lower utilization and lower expansion throughout the
continuum of care. Attention to subnational implementation frameworks and processes is
critical to large-scale national program success. Special care must be taken to ensure
coverage to all marginalized sections of the population.
Trends and equity in nutrition interventions delivered through the health system in India
Purnima Menon (IFPRI)
This paper analyses data from the third and fourth rounds of the National Family Health
Survey, along with a key set of interventions in India’s policy frameworks, spanning the
continuum of care for maternal, newborn and child health and nutrition. Results show that
although the coverage of all health and nutrition interventions improved between 2006 and
2016, achieving full coverage of interventions to every woman and every child remains a
significant challenge. Several opportunities remain for better integration of health and
nutrition interventions. As India looks ahead to the Sustainable Development Goals a
stronger focus on closing gaps in coverage, state-by-state, district-by-district is needed.