A set of global nutrition targets for maternal and child nutrition together with diet related non communicable diseases ( to be achieved by 2025 was endorsed by the World Health Assembly in 2013 These targets provide goals against which progress towards ending malnutrition in all its forms can be measured and contribute to the Sustainable Development Goals This data note describes trends in multiple forms of malnutrition and NCD outcomes at the national, state, and district levels for India using survey data from NFHS 3 2005 06 NFHS 4 2015 2016 and NFHS 5 2019 2021 Insights on other malnutrition targets such as anemia and breastfeeding will be forthcoming

A set of diet-related global non-communicable diseases (NCD) targets, to be achieved by 2025, was endorsed by the World Health Assembly (WHA) in 2013. A sub-set of those targets are directly nutritionrelated. This Data Note describes the current levels of a set of key NCD-related outcomes at the districtlevel in India, summarizing data from the recently released district fact sheets of the National Family Health Survey.

BACKGROUND| Healthy diets are necessary for optimal growth and to carry out daily mental and physical tasks. Unhealthy diets drive all forms of malnutrition and dietary risks are the number one risk factor globally for deaths and disability (Global Burden of Disease collaborators, 2019). Given the importance of diet as a key driver of health and wellbeing, this Data Note examines available data from three rounds of India’s National Family Health Surveys (NFHS) on food consumption patterns of adult men and women. MEASUREMENT| NFHS asks women (15-49 years) and men (15-54 years) how frequently (daily, weekly, occasionally or never) they consume nine food groups including two unhealthy food groups (Figure 1). The 2020 Nutrient Requirements for Indians outlines the quantity per day of vegetarian foods to be consumed as part of a balanced diet (ICMR-NIN, 2020). The guidelines indicate that pulses can be replaced with animal-source foods for non-vegetarians. Thus, for this Data Note we constructed an additional indicator –daily consumption of pulses or egg or fish or chicken or meat –to estimate any protein consumption (Figure 1). Estimates are first presented at the national level to provide an overall view of how diets have changed from 2005-06 to 2019-21. On subsequent pages, we show trends between 2015-16 and 2019-21 by state and district. USE| This data note provides a broad view of diet patterns among adults and should be used for further inquiry by stakeholders including researchers, policymakers, and program staff at multiple levels. We recognize that NFHS is not a detailed dietary survey and does not ask about individual food items or the quantity of food consumed. Thus, this data note should be used as a starting point for discussion and to identify major areas of improvement in consumption and measurement.

Malnutrition is endemic in India. In 2015-16 some 38% of preschool children were stunted and 21% were wasted, while more than half of Indian mothers and children were anemic. There are many posited explanations for the high rates of malnutrition in India, but surprisingly few discuss the role of Indian diets, particularly the affordability of nutritious diets given low wages and the significant structural problems facing India’s agricultural sector. This study was undertaken to address knowledge gaps around the affordability of nutritious diets in rural India. To do so we used nationally representative rural price and wage data to estimate the least cost means of satisfying India-specific dietary recommendations, referred to as the Cost of a Recommended Diet (CoRD), and assess the affordability of this diet relative to male and female wages for unskilled laborers. Although we find that dietary costs increased substantially over 2001-2011 for both men and women, rural wage rates increased more rapidly, implying that nutritious diets became substantially more affordable over time. However, in absolute terms nutritious diets in 2011 were still expensive relative to unskilled wages, constituting approximately 50-60% of male and about 70-80% of female daily wages, and were often even higher relative to minimum wages earned from the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA). Since many poor households have significant numbers of dependents and substantial non-food expenditure requirements, it follows that nutritious diets are often highly unaffordable for the rural poor; we estimate that 45-64% of the rural poor cannot afford a nutritious diet that meets India’s national food-based dietary guidelines. Our results point to the need to more closely monitor food prices through a nutritional lens, and to shift India’s existing food policies away from their heavy bias towards cereals. Achieving nutritional security in India requires a much more holistic focus on improving the affordability of the full range of nutritious food groups and ensuring that economic growth results in sustained income growth for the poor.

Given its continent-like diversity, India’s epidemiological, nutritional, and demographic transitions are occurring in a staggered fashion, with high state-level variances. In many parts of the country, high rates of undernutrition co-exist with equally high and increasing rates of overweight and obesity. Further, the incidence of non-communicable diseases (NCDs) as a leading cause of mortality is increasing, even as the communicable, maternal, neonatal and nutritional causes (or the “Millennium Development Goals (MDG) conditions”) are coming down. Indeed, India has witnessed inconsistent progress towards the MDGs, and even in states where absolute levels of “MDG conditions” are still high, the NCD proportion is growing rapidly. The imperative is for a realignment of policy responding to fast-changing subnational realities, through greater integration between health and nutrition policy at every level of governance.

This open access book examines the interactions between India’s economic development, agricultural production, and nutrition through the lens of a “Food Systems Approach (FSA).” The Indian growth story is a paradoxical one. Despite economic progress over the past two decades, regional inequality, food insecurity and malnutrition problems persist. Simultaneously, recent trends in obesity along with micro-nutrient deficiency portend to a future public health crisis. This book explores various challenges and opportunities to achieve a nutrition-secure future through diversified production systems, improved health and hygiene environment and greater individual capability to access a balanced diet contributing to an increase in overall productivity. The authors bring together the latest data and scientific evidence from the country to map out the current state of food systems and nutrition outcomes. They place India within the context of other developing country experiences and highlight India’s status as an outlier in terms of the persistence of high levels of stunting while following global trends in obesity. This book discusses the policy and institutional interventions needed for promoting a nutrition-sensitive food system and the multi-sectoral strategies needed for simultaneously addressing the triple burden of malnutrition in India.