Despite of decline in undernutrition level in last decade, the largest chunk of global undernourished under-five children is in India with about two-fifths of children being stunted and underweight, and one-fifth were wasted in 2015–2016. The improvement in average annual decline in proportion of underweight children is evident from previous two decades. This decline has improved from 0.42 percentage point per year during 1991–2005  to 0.68 percentage point (2005–2006 to 2015–2016). However, there exists a wide geographical diversity in childhood undernutrition. To achieve the global nutritional targets of World Health Assembly 2012, and SDGs targets, it is pertinent to understand spatial distribution and their sociodemographic and biomedical predictors.
We found that underweight and stunting level among under-five is highly concentrated in central and western Indian states of Rajasthan, Gujarat, Bihar, Uttar Pradesh, Jharkhand, Chhattisgarh and Madhya Pradesh. This is in coherence with national priorities of Govt of India. The twelfth five-year plan of India (2012–2017) focused on reducing the malnutrition level by half by 2017 with a special focus on the above states . However, our results showed the sluggish decline during 2005–16 and is highly unlikely to achieve the targets by the year 2017. In addition, the states with better socioeconomic indicators (Non-Empowered Action Group states like Maharashtra and Karnataka) have huge proportion of wasted children. Maharashtra has substantial proportion of underweight children higher than EAG states like Odisha and Assam. The district-level analysis revealed the clustering of child undernutrition at southern districts of Odisha and Chhattisgarh, northern districts of Odisha and southern districts of Jharkhand, northern districts of Bihar and northwestern districts of West Bengal, northern districts of Uttar Pradesh and boarder districts of Uttar Pradesh, Madhya Pradesh, Rajasthan, Maharashtra and Gujarat.
These regional variations in child undernutrition are a combination of different socioeconomic variations, feeding and dietary practices, and variation in implementation of different nutritional program like Integrated Child Development Programme (ICDS) . Some of the studies found an indirect relationship between access to ICDS services and undernutrition status of children in Indian states [2, 7, 19]. The utilization of ICDS services from 10 to 90% with high access to services among the states where malnutrition levels are lower and vice versa . The current decline in undernutrition in the EAG states is faster because of greater budgetary allocation through National Health Mission . However, the decline has been slow due to multiple factors associated to undernutrition.
The multivariate regression and scatter plot results indicated that multiple factors like use of clean fuel for cooking, use of iodized salt, mother’s education, GDP of the districts, feeding of breast milk and complementary foods are associated to different child nutrition indicators. It is found that the higher proportion of use of clean fuel is significantly associated with low stunting and underweight level of children which corroborates the findings of several other studies in India [3, 4]. Studies also showed that the indoor air pollution has significant association on child’s respiratory health which may lead to undernutrition among children [12, 28].
This was evident from previous studies that lack of use of adequately iodized salt is associated with significantly higher prevalence of malnutrition and child mortality (neonatal, infant and children aged < 5 year). However, this finding, being a cross-sectional study, does not necessarily infer the causal association between the use of iodized salt and malnutrition. Moreover, it suggested that adequately iodized salt fails to reach families who could potentially benefit the most [14, 27].
The regression result found appropriate breastfeeding practices and feeding practices are important for better nutrition among children. There are several studies indicating that inappropriate feeding practices can have greater consequences for the growth, development and survival of infants and children in Asian countries [8, 11, 26]. Foods are “gifts” of nature; human beings only cultivate the crops and rear or hunt for the animals as the case may be . Nonetheless, economic growth and industrialization in recent decades led to increased production of food in India. Private distributors can use their market power to achieve high penetration of beneficial foods and micronutrients by coupling the accessibility of commercial markets with comprehensive social marketing campaigns. The private sector also represents largely untapped financial and human resources that can be mobilized in support of nutrition aims. Efforts by private–public partnerships at the international level—e.g., the Alliance for a Green Revolution in Africa (AGRA -), or the Global Alliance for Improved Nutrition (GAIN)—can be replicated at national and subnational levels and used to promote local farming, involve local commercial outlets in the distribution of nutritious food products, or support other elements of the national nutrition strategy. Involving the private sector in efforts to achieve nutrition goals carries risks—e.g., the risk of undue corporate influence on public policy, the risk of distortions in the nutrition agenda toward activities of interest to the private sector, and others. These risks are especially worrisome in countries with weak government capacity, among them many of the countries with the highest burden of undernutrition. Some guidance is available now, emphasizing the importance of developing mandatory rather than voluntary codes of conduct, and the UN Standing Committee on Nutrition has established a working group to provide guidance to countries on private sector engagement in food and nutrition programs .
There is no magic technological bullet to solve the problem of undernutrition. Long-term investments in the role of women—through education, economic, social and political empowerment—can be a way to deliver sustainable improvements in maternal and child nutrition, and in the health of women and children more generally. The compelling logic of this scientific evidence is that governments need national plans to scale up nutrition interventions, systems to monitor and evaluate those plans, and laws and policies to enhance the rights and status of women and children .
This study provided cross-sectional ecological associations which is confounded by ecological fallacy and weak evidence for causality, however, temporal ecological data, being based on nationally representative serial cross-sectional studies, may provide robust evidence.
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