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Comprehensive

National Nutrition

Survey

2016-2018

Birth to Adolescence

ii

Suggested citation:

Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF and Population Council. 2019. Comprehensive National Nutrition Survey (CNNS)

National Report. New Delhi.

Version 1.0

For additional information about the Comprehensive National

Nutrition Survey, please contact:

Ministry of Health & Family Welfare

Government of India

Child Health Division

Nirman Bhavan, New Delhi 110 018

Telephone: 011-23061334, 23063398

Email: chmohfw@gmail.comUNICEF

Nutrition Section

73 Lodi Estate

New Delhi 110 003

Telephone: 011-24690401, 24691410

Email: ind.cnns@unicef.org

iii

Contributors

MoHFW

Ajay Khera

Sila Deb

UNICEF

Robert Johnston

Praween K. Agrawal

Population Council

Sowmya Ramesh

Nizamuddin Khan

Akash Porwal

Avina Sarna

Rajib Acharya

iv v

Contents

List of tables vii

List of fi gures xiv

Acknowledgements xix

Abbreviations xxi

Chapter 1: Introduction and objective 1

1.1

Purpose and objectives of the CNNS 6

Chapter 2: Methods 13

Key fi ndings 15

2.1

Sample size 15

2.2

Sample design 16

2.3

Survey implementation 17

2.4

Household survey interview 19

2.5

Anthropometric measurements 25

2.6

Biological sample collection 29

2.7

Pilot testing 32

2.8

Data management and analysis 33

2.9

Response rates 34

2.10

Sampling errors and limitations on use of data 34

2.11

Ethical considerations 35

Chapter 3: Characteristics of the study sample 45

Key fi ndings 47

3.1

Importance of background characteristics 47

3.2 Sample age distribution of children and adolescents 48 3.3 Socio-demographic and behaviour characteristics 49 Chapter 4: Infant and young child feeding and diets 59

Key fi ndings 61

4.1 Infant and young child feeding (IYCF) practices 62 vi

4.2 Food consumption among children aged 2-9 years and adolescents

aged 10-19 years 71
Chapter 5: Anthropometric status of children and adolescents 101

Key fi ndings 103

5.1

Anthropometric measurements 104

5.2 Measures of undernutrition, overweight and obesity 105 5.3

Prevalence of malnutrition 108

Chapter 6: Anaemia and iron defi ciency 155

Key fi ndings 157

6.1.

Anaemia 157

6.2

Iron defi ciency 164

Chapter 7: Micronutrients 177

Key fi ndings 179

7.1

Vitamin A defi ciency 180

7.2

Vitamin D defi ciency 186

7.3

Zinc defi ciency 189

7.4

Vitamin B12 and folate defi ciency 191

7.5

Urinary iodine status 192

Chapter 8: Markers of non-communicable diseases 211

Key fi ndings 213

8.1

Fasting plasma glucose and HbA1c 214

8.2

Lipid profi le 217

8.3

Renal function 224

8.4

Blood pressure 227

References 247

Annexes 251

Annex 1: Anthropometric data quality 252

Annex 2: CNNS Technical Advisory Group and implementing agencies 288 vii

List of Tables

Table 2.1: Information collected in the CNNS by age group, India,

CNNS 2016-18 20

Table 2.2: Languages of CNNS questionnaires by state, India,

CNNS 2016-18 21

Table 2.3: Anthropometric measurements taken in CNNS by age group, India, CNNS 2016-18 25 Table 2.4: Number of primary sampling units (PSUs) and target sample size by state, India, CNNS 2016-18 37 Table 2.5: Target sample size for household survey and anthropometric measurements by age group, India, CNNS 2016-18 38 Table 2.6: Target sample size for biological sample collection by age group, India, CNNS 2016-18 39 Table 2.7: Specifi c nutritional biochemical indicators and infl ammatory markers evaluated in the three age groups, India, CNNS 2016-18 40 Table 2.8: Biochemical indicators and analysis methodology, India,

CNNS 2016-18 41

Table 2.9: Data collection period, sample size achieved in individual interview and biological sample collection by age group and response rate by state, India, CNNS 2016-18 42 Table 3.1: Percent distribution of sampled children aged 0-4 years by selected characteristics, India, CNNS 2016-18 56 Table 3.2: Percent distribution of sampled children aged 5-9 years by selected characteristics, India, CNNS 2016-18 57 Table 3.3: Percent distribution of adolescents aged 10-19 years by selected characteristics, India, CNNS 2016-18 58 Table 4.1: Percent distribution of IYCF practices among children 0-23 months by selected background characteristics, India, CNNS 2016-18 83 Table 4.2: Percentage of children aged 6-23 months receiving minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and iron-rich foods by breastfeeding status and selected background characteristics, India, CNNS 2016-18 85 Table 4.3: Percentage of children aged 6-23 months with minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich foods by state, India, CNNS 2016-18 87 viii Table 4.4: Percentage of children aged 2-4 years consuming specifi c foods during the previous 24 hours by selected background characteristics,

India, CNNS 2016-18 89

Table 4.5: Percentage of children aged 2-4 years consuming specifi c foods during the previous 24 hours by state, India, CNNS 2016-18 91 Table 4.6: Percentage of children aged 5-9 years consuming specifi c foods at least once per week by selected background characteristics,

India, CNNS 2016-18 93

Table 4.7: Percentage of children aged 5-9 years consuming specifi c foods at least once per week by state, India, CNNS 2016-18 95 Table 4.8: Percentage of children aged 10-19 years consuming specifi c foods at least once a week by selected background characteristics, India,

CNNS 2016-18 97

Table 4.9: Percentage of children aged 10-19 years consuming specifi c foods at least once per week by state, India, CNNS 2016-18 99 Table 5.1: Anthropometric measurements for children and adolescents by age, India, CNNS 2016-18 104 Table 5.2: Types of malnutrition and reference cut-offs, India,

CNNS 2016-18 107

Table 5.3: Percentage of children aged 0-4 years classifi ed as malnourished according to height-for-age, weight-for-height, and weight-for-age by selected background characteristics, India,

CNNS 2016-18 121

Table 5.4: Percentage of children aged 0-4 years classifi ed as malnourished according to height-for-age, weight-for-height, and weight-for-age by state, India, CNNS 2016-18 123 Table 5.5: Percentage of children aged 0-4 years classifi ed as malnourished by TSFT for age and percentage of children aged 1-4 years classifi ed as malnourished by SSFT for age by selected background characteristics, India, CNNS 2016-18 125 Table 5.6: Percentage of children aged 0-4 years classifi ed as malnourished by TSFT and percentage of children from 1-4 years classifi ed as malnourished by SSFT for age (Z-score: <-2SD, <-3SD, >+

2SD, >+3SD), by state, India, CNNS 2016-18 127

Table 5.7: Percentage of children aged 6-59 months classifi ed as malnourished according to MUAC-for-age (Z-score: <-3SD, <-2SD) by selected background characteristics, India, CNNS 2016-18 129 ix Table 5.8: Percentage of children aged 6-59 months classifi ed as malnourished according to MUAC-for-age (Z-score: <-3SD, <-2SD) by state, India, CNNS 2016-18 131 Table 5.9: Percentage of children aged 6-59 months classifi ed as malnourished according to absolute MUAC (< 115 mm, < 125 mm) by selected background characteristics, India, CNNS 2016-18 132 Table 5.10: Percentage of children aged 6-59 months classifi ed as malnourished according to absolute MUAC (< 115 mm, < 125 mm) by state, India, CNNS 2016-18 134 Table 5.11: Percentage of children aged 5-9 years classifi ed as stunted and underweight according to height-for-age (Z-score: <-3SD, <-2SD) and weight-for-age (Z-score: <-3SD, <-2SD) by selected background characteristics, India, CNNS 2016-18 135 Table 5.12: Percentage of children aged 5-9 years classifi ed as stunted and underweight according to height-for-age (Zp-score: <-3SD, <-2SD) and weight-for-age (Z-score: <-3SD, <-2SD) by state, India, CNNS 2016-18 137 Table 5.13: Percentage of children aged 5-9 years classifi ed as malnourished according to BMI-for-age (Z-score: <-3SD, <-2SD, >+1SD, >+2SD) by selected background characteristics, India, CNNS 2016-18 139 Table 5.14: Percentage of children aged 5-9 years classifi ed as malnourished according to BMI-for-age (Z-score: <-3SD, <-2SD, >+1SD, >+2SD) by state, India, CNNS 2016-18 141 Table 5.15: Percentage of adolescents aged 10-19 years classifi ed as malnourished according to BMI-for-age (Z-score: <-3SD, <-2SD, >+1SD, >+2SD) by selected background characteristics, India, CNNS 2016-18 142 Table 5.16: Percentage of adolescents aged 10-19 years classifi ed as malnourished according to BMI-for-age (Z-score: <-3SD, <-2SD, >+1SD, >+2SD) by state, India, CNNS 2016-18 145 Table 5.17: Percentage of children aged 5-9 years classifi ed as malnourished or overweight/obese according to TSFT, SSFT, MUAC and waist circumference, by selected background characteristics,

India, CNNS 2016-18 147

Table 5.18: Percentage of children aged 5-9 years classifi ed as malnourished or overweight/obese according to TSFT, SSFT, MUAC and waist circumference by state, India, CNNS 2016-18 149 Table 5.19: Percentage of children aged 10-19 years classifi ed as malnourished or overweight/obese according to TSFT, SSFT, MUAC and waist circumference by selected background characteristics,

India, CNNS 2016-18 151

x Table 5.20: Percentage of children aged 10-19 years classifi ed as malnourished or overweight/obese according to TSFT, SSFT, MUAC and waist circumference by state, India, CNNS 2016-18 153 Table 6.1: Percentage of children aged 1-4 years classifi ed as having anaemia and iron defi ciency by selected background characteristics,

India, CNNS 2016-18 170

Table 6.2: Percentage of children aged 1-4 years classifi ed as having anaemia and iron defi ciency by state, India, CNNS 2016-18 171 Table 6.3: Percentage of children aged 5-9 years classifi ed as having anaemia and iron defi ciency by selected background characteristics,

India, CNNS 2016-18 172

Table 6.4: Percentage of children aged 5-9 years classifi ed as having anaemia and iron defi ciency by state, India, CNNS 2016-18 173 Table 6.5: Percentage of adolescents aged 10-19 years classifi ed as having anaemia and iron defi ciency by selected background characteristics, India, CNNS 2016-18 174 Table 6.6: Percentage of adolescents aged 10-19 years classifi ed as having anaemia and iron defi ciency by state, India, CNNS 2016-18 175 Table 7.1: Percentage of children aged 1-4 years classifi ed as having vitamin A, vitamin D and zinc defi ciency by selected background characteristics, India, CNNS 2016-18 193 Table 7.2: Percentage of children aged 5-9 years classifi ed as having vitamin A, vitamin D and zinc defi ciency by selected background characteristics, India, CNNS 2016-18 194 Table 7.3: Percentage of adolescent aged 10-19 years classifi ed as having vitamin A, vitamin D and zinc defi ciency by selected background characteristics, India, CNNS 2016-18 195 Table 7.4: Percentage of children age 1-4 years classifi ed as having vitamin A, vitamin D and zinc defi ciency by state, India, CNNS 2016-18 196 Table 7.5: Percentage of children aged 5-9 years classifi ed as having vitamin A, vitamin D and zinc defi ciency by state, India, CNNS 2016-18 197 Table 7.6: Percentage of adolescents aged 10-19 years classifi ed as having vitamin A, vitamin D and zinc defi ciency by state,

India, CNNS 2016-18 198

Table 7.7: Percentage of children aged 1-4 years classifi ed as having vitamin B12 defi ciency and folate defi ciency by selected background characteristics, India, CNNS 2016-18 199 xi Table 7.8: Percentage of children aged 5-9 years classifi ed as having defi ciency of vitamin B12 and Folate by selected background characteristics, India, CNNS 2016-18 200 Table 7.9: Percentage of adolescents aged 10-19 years classifi ed as having defi ciency of vitamin B12 and Folate by selected background characteristics, India, CNNS 2016-18 201 Table 7.10: Percentage of children aged 1-4 years classifi ed as having defi ciency of vitamin B12 and Folate by state, India, CNNS 2016-18 202 Table 7.11: Percentage of children aged 5-9 years classifi ed as having defi ciency of vitamin B12 and Folate by state, India, CNNS 2016-18 203 Table 7.12: Percentage of adolescents aged 10-19 years classifi ed as having defi ciency of vitamin B12 and Folate by state,

India, CNNS 2016-18 204

Table 7.13: Iodine status as measured by median urinary iodine concentration among children aged 1-4 years by selected background characteristics, India, CNNS 2016-18 a 205
Table 7.14: Iodine status (urinary iodine concentration: median and low) in children aged 5-9 years by selected background characteristics,

India, CNNS 2016-18 206

Table 7.15: Iodine status (urinary iodine concentration: median and low) in adolescents aged 10-19 years by selected background characteristics,

India, CNNS 2016-18 207

Table 7.16: Iodine status (urinary iodine concentration: median and low) in children aged 1-4 years by state, India, CNNS 2016-18 208 Table 7.17: Iodine status (urinary iodine concentration: median and low) in children aged 5-9 years by state, India, CNNS 2016-18 209 Table 7.18: Iodine status (urinary iodine concentration: median and low) in adolescents aged 10-19 years by state, India, CNNS 2016-18 210 Table 8.1: Percentage of children aged 5-9 years with pre-diabetic and diabetic status by selected background characteristics, India,

CNNS 2016-18 229

Table 8.2: Percentage of adolescents aged 10-19 years with pre-diabetic and diabetic status by selected background characteristics, India,

CNNS 2016-18 230

Table 8.3: Percentage of children aged 5-9 years with pre-diabetic and diabetic status by state, India, CNNS 2016-18 231 Table 8.4: Percentage of adolescents aged 10-19 years with pre-diabetic and diabetic status by state, India, CNNS 2016-18 232 xii Table 8.5: Percentage of children aged 5-9 years with elevated glycosylated haemoglobin concentration (HbA1c) by selected background characteristics, India, CNNS 2016-18 233 Table 8.6: Percentage of adolescents aged 10-19 years with elevated glycosylated haemoglobin concentration (

HbA1c) by selected background

characteristics, India, CNNS 2016-18 234 Table 8.7: Percentage of children aged 5-9 years with elevated glycosylated haemoglobin concentration (HbA1c) by state,

India, CNNS 2016-18 235

Table 8.8: Percentage of adolescents aged 10-19 years with elevated glycosylated haemoglobin concentration (HbA1c) by state, India,

CNNS 2016-18 236

Table 8.9: Percentage of children aged 5-9 years with high total cholesterol, high LDL, low HDL and high triglycerides by selected background characteristics, India, CNNS 2016-18 237 Table 8.10: Percentage of adolescents aged 10-19 years with high total cholesterol, high LDL, low HDL and high triglycerides by selected background characteristics, India, CNNS 2016-18 238 Table 8.11: Percentage of children aged 5-9 years with high total cholesterol, high LDL, low HDL and high triglycerides by state, India,

CNNS 2016-18 239

Table 8.12: Percentage of adolescents aged 10-19 years with high total cholesterol, high LDL, low HDL and high triglycerides by state, India,

CNNS 2016-18 240

Table 8.13: Percentage of children aged 5-9 years with high serum creatinine by selected background characteristics, India, CNNS 2016-18 241 Table 8.14: Percentage of adolescents aged 10-19 years with high serum creatinine by selected background characteristics, India, CNNS 2016-18 242 Table 8.15: Percentage of children aged 5-9 years with high serum creatinine by state, India, CNNS 2016-18 243 Table 8.16: Percentage of adolescents aged 10-19 years with high serum creatinine by state, India, CNNS 2016-18 244 Table 8.17: Percentage of adolescents aged 10-19 years classifi ed as hypertensive by selected background characteristics, India, CNNS 2016-18 245 Table 8.18: Percentage of adolescents aged 10-19 years classifi ed as hypertensive by state, India, CNNS 2016-18 246 Table A1: Sampling errors for anthropometric indicators for total sample by age groups, India, CNNS 2016-18 252 xiii Table A2: Sampling errors for anthropometric indicators for urban sample by age groups, India, CNNS 2016-18 254 Table A3: Sampling errors for anthropometric indicators for rural sample by age groups, India, CNNS 2016-18 256 Table A4: Sampling errors for biochemical indicators for total sample by age groups, India, CNNS 2016-18 258 Table A5: Summary statistics of technical error of measurement (TEM) of height by state, India, CNNS 2016-18 260 Table A6: Summary statistics of technical error of measurement (TEM) of MUAC by state, India, CNNS 2016-18 261 Table A7a: Summary statistics of technical error of measurement (TEM) of TSFT by state, India, CNNS 2016-18 262 Table A7b: Summary statistics of technical error of measurement (TEM) of SSFT by state, India, CNNS 2016-18 263 Table A8a: Percentage of children aged under fi ve years with missing data on Z-scores of anthropometric measurements by state, India,

CNNS 2016-18 264

Table A8b: Percentage of children aged under fi ve years with fl agged cases on Z-scores of anthropometric measurements by state, India,

CNNS 2016-18 265

Table A9: Distribution of the month of birth of children under 5 years old by state, India, CNNS 2016-18 267 Table A10: Distribution of the number of month of following completed years of children under 5 years old by state, India, CNNS 2016-18 270 Table A11: Distribution of the sample by age in completed years of children under 5 years old by state, India, CNNS 2016-18 275 Table A12: Digit preference score (DPS) of the anthropometric measures of children under 5 years old by state, India, CNNS 2016-18 277 Table A 13: Standard deviation (SD) of Z-scores of the anthropometric outcomes of children under 5 years old by state, India, CNNS 2016-18 281 Table A14: Skewness of Z-scores of the anthropometric outcomes of children under 5 years old by state, India, CNNS 2016-18 282 Table A15: Kurtosis of Z-scores of the anthropometric outcomes of children under 5 years old by state, India, CNNS 2016-18 283 Table A16: Number of cases and proportions of mismatches between length/height measurement position and recommended position of children under 5 years old by state, India, CNNS 2016-18 287 xiv

List of fi gures

Figure 1.1: The burden of malnutrition among children and adults in

India (presented in millions) 4

Figure 1.2: Nutrition data availability and gaps in pre-school children aged 0-4 years 8 Figure 1.3: Nutrition data availability and gaps in school age children/early adolescents aged 5-14 years 9 Figure 1.4: Nutrition data availability and gaps in adolescents aged 15-19 years 10 Figure 1.5: Partnership for CNNS implementation 11

Figure 2.1:

Selected districts and PSUs, India, CNNS 2016-18 18 Figure 3.1: Mother"s level of schooling by child age group, India, CNNS 2016-18 50 Figure 3.2: Percentage of mothers/caregivers of children a ged 0-4 years exposed to any mass media, India, CNNS 2016-18 51 Figure 3.3. Percentage of adolescents aged 10-19 years in the poorest and richest wealth quintile households by state, India, CNNS 2016-18 52 Figure 3.4: Type of diet consumed by age group, India, CNNS 2016-18 53 Figure 3.5: Percentage of mothers/caregivers of children aged 0-4 years consuming a vegetarian diet during the previous week by state, India,CNNS 2016-18 54 Figure 3.6: Percentage of respondents of children aged 0-4 years by relationship to child, India, CNNS 2016-18 55 Figure 4.1: Infant feeding practices, India, CNNS 2016-18 64 Figure 4.2: Infant and young child feeding practices by child age, India,

CNNS 2016-18 65

Figure 4.3: Complementary feeding indicators for children aged 6-23 months 66 Figure 4.4: Feeding practices among breastfed and non-breastfed children aged 6-23 months, India, CNNS 2016-18 67 Figure 4.5: Minimum meal frequency and minimum dietary diversity by child age among breastfed and non-breastfed children, India, CNNS 2016-18 68 Figure 4.6: Percentage of children aged 6-23 months receiving a minimum acceptable diet by state, India, CNNS 2016-18 70 Figure 4.7: Food groups consumed during the previous 24 hours among children aged 2-4 years by state, India, CNNS 2016-18 72

Figure 4.8:

Daily consumption of various food groups among children aged

5-9 years by state, India, CNNS 2016-18 75

Figure 4.9: Daily consumption of various food groups among adolescents aged 10-19 years by state, India, CNNS 2016-18 79 Figure 5.1: Types of malnutrition and reference measures, India, CNNS 2016-18 106 xv Figure 5.2: Percentage of stunting among children aged 0-4 years by state, India, CNNS 2016-18 108 Figure 5.3: Percentage of wasting among children aged 0-4 years by state,

India, CNNS 2016-18 109

Figure 5.4: Percentage of underweight among children aged 0-4 years by state, India, CNNS 2016-18 110 Figure 5.5: Percentage of stunting, wasting, underweight and MUAC < 125 mm among children under fi ve by age in months, India, CNNS 2016-18 111 Figure 5.6: Percentage of stunting, low BMI, underweight and overweight among children and adolescents aged 5-19 years by age, India, CNNS 2016-18 113 Figure 5.7: Percentage of stunting and low BMI among children and adolescents aged 5-19 years by sex and age, India, CNNS 2016-18 115 Figure 5.8: Percentage of overweight among adolescents aged 10-19 years by state, India, CNNS 2016-18 116

Figure 5.9:

Percentage of overweight and high waist circumference among children and adolescents aged 5-19 years by sex and age, India, CNNS 2016-18 117 Figure 5.10: Percentage of high TSFT-for-age and high SSFT-for-age among children and adolescents aged 5-19 years by sex and age, India, CNNS 2016-18 119 Figure 5.11: Double burden of malnutrition in individuals by age groups,

India, CNNS 2016-18 120

Figure 6.1: Severity of anaemia across the three age groups, India,

CNNS 2016-18 159

Figure 6.2: Prevalence of anaemia by sex among children and adolescents aged 1-19 years, India, CNNS 2016-18 160 Figure 6.3: Prevalence of anaemia by household wealth quintile among children and adolescents, India, CNNS 2016-18 161 Figure 6.4a: Prevalence of anaemia as a public health problem among children aged 1-4 years, India, CNNS 2016-18 162 Figure 6.4b: Prevalence of anaemia as a public health problem among children aged 5-9 years, India, CNNS 2016-18 163

Figure 6.4c:

Prevalence of anaemia as a public health problem among adolescents aged 10-19 years, India, CNNS 2016-18 164

Figure 6.5:

Prevalence of anaemia and iron defi ciency by sex among children and adolescents aged 1-19 years, India, CNNS 2016-18 165 Figure 6.6: Prevalence of anaemia and iron defi ciency among children and adolescents, India, CNNS 2016-18 166 Figure 6.7: Prevalence of iron defi ciency among of children aged 1-4 years by state, India, CNNS 2016-18 167 xvi Figure 6.8: Prevalence of iron defi ciency among children aged 5-9 years by state, India, CNNS 2016-18 168quotesdbs_dbs47.pdfusesText_47

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