If you ever thought that malnutrition is something that affects kids in distant lands or just villages, it is time to change that narrative. The most recent National Family Health Survey‑5 (NFHS-5, 2019-21)
reports that 32.1% of Indian children under five are underweight. National averages have recorded modest improvement over previous rounds but remain markedly uneven at the district level – indeed, a set of “high-risk” districts disproportionately carry the burden of undernutrition.
A 2022 analysis of district-level malnutrition data identified over 100 districts as “critical” or “very serious” for under-5 undernutrition. In some districts, the share of underweight children is over the national mean, explains Dr Vimal Pahuja, MD, Associate Director, Internal Medicine & Metabolic Physician, Dr LH Hiranandani Hospital, Mumbai, pointing to clusters where underweight prevalence might be 20-40% higher than the national average.
From the viewpoint of endocrinology and metabolic development, this reflects more than just a lack of sufficient calories; it indicates the cellular and hormonal adaptation to chronic nutritional stress. Poor maternal nutrition, repeated infections, micronutrient deficiency, and low dietary diversity – all affect high-risk districts and act to truncate growth potential. Chronic undernutrition in utero and early infancy dysregulates hormonal axes (e.g., the insulin-like growth factor system), reduces lean mass accrual, and impairs immune resilience.
This metabolic programming results in children who are underweight now — but perhaps predisposed to adverse metabolic outcomes if exposed later to calorie-rich diets, the so-called “thrifty phenotype”.
This makes the effect multiply: undernutrition concentrated in select districts, rather than being uniformly distributed, puts at risk generations suffering from poorer physical growth, poorer cognitive development, and later-life metabolic disease – a poor return on national human-capital potential.
It is paramount to understand these patterns at the district level, as blanket national averages mask persistent pockets of severe undernutrition. Therefore, policy actions should be aimed at “high-risk” districts identified through data, such as those that have been flagged in NFHS-5 and subsequent analyses, with context-specific nutritional interventions.
Effective strategies need to look beyond calories to maternal nutrition during pregnancy, micronutrient-fortified foods and protein-rich local foods. Furthermore, it is important for them to also have access to balanced macro- and micronutrient nutrition at schools, along with periodic growth screening (anaemia, vitamin D, micronutrient deficiencies), and sanitation and infection control measures. Only through such targeted efforts can we avoid the risk of leaving whole districts, and possibly a generation, metabolically fragile, stunted, underweight, and with compromised long-term health and productivity.
Dr Rahul Verma, Director of Paediatrics and Neonatology at Sir H. N. Reliance Foundation Hospital, says, “Headline facts show children in the at-risk districts are 25% more likely to be underweight, but this is more than a mere figure; it is a poignant commentary on our failure to safeguard the most susceptible. As a paediatrician, I don’t see percentages; I see the rib cages of toddlers who have lost the race before they were even born.”
It’s all being driven by a “triple threat” that has been screaming at us through the NFHS-5 data.
First of all, people are experiencing “inherited hunger”. The Aspirational Distressed Districts begin their narrative in the womb. The NFHS-5 figures indicate that more than 50% of this population suffers from anaemia during pregnancy. Children are being born with low fuel reserves because mothers are left depleted. It’s nothing short of devastating to deal with a child at birth who has been literally losing a war even before birth, having been lost to a life of malnutrition even at conception.
Second is the leaking gut. In these areas of high vulnerability, it is not just about empty plates but about dangerous environments. And because children are constantly being exposed to poor sanitation environments, they get something called environmental enteropathy. Essentially, it is where the gut becomes irritated while you’re a child, and you just aren’t able to absorb your nutrients. It is like pouring water into a broken bucket. We put food into these children, but the environment is taking it back.
Finally is the issue of “Hidden Hunger”. The diet reaching these families may be staples like carbohydrates and protein. This food might satisfy the empty stomach, but provides nothing for the growing brain and body. The child may not appear as if it is starving to a layman if it is just consuming rice or rotis. It may be hollow from a medical perspective.
However, if we’re going to fill this gap of 25%, we have to stop looking at it from a logistics perspective and shift it from being a humanitarian crisis to an emergency. We have to address maternal nutrition and aggressive gastrointestinal health or risk losing an entire generation to this silent theft.
