Diet Quality, Water and Toilets Remain a Lingering Challenge for Undernutrition in India
Authors: Cyriac Shruthi , Menon Purnima , Aguayo Victor 
Published: November 2023

Background & objectivesInfant and young child feeding (IYCF) practices are critical to child nutrition. Emerging evidence is suggesting important roles for water, sanitation and hygiene (WASH) too. Less is known, however on the intersection of these two inputs. We studied the joint effects of IYCF and WASH on child undernutrition in India, a country with very high levels of stunting and wasting, using nationally representative survey data.MethodsWe used data from ~18,463 children 0–23.9 month old from the 3rd round of India's National Family Health Survey, conducted in 2005–06, the most recent publicly available dataset for India. Outcomes included child height‐for‐age, weight‐for‐age, weight‐for‐height z‐scores (HAZ, WAZ and WHZ), stunting, underweight and wasting. Main predictor variables included IYCF indicators (breastfeeding and complementary feeding) and WASH indicators (water source, toilet type, disposal of child stools). Linear and logistic regression analyses were used, accounting for clustering. We tested for interactions between IYCF and WASH variables, adjusting for child, maternal and household characteristics and state and urban/rural residence. We interpreted the current relevance of our findings using available factsheets of a more recent survey dataset (2013–14) for which original data are not released to public domain.ResultsIYCF practices in India are poor, especially complementary feeding practice (only 35% of children 6–23 mo achieved minimum diet diversity in 2005–06; this worsened to almost 22% in 2013–14). Sanitation conditions too are poor (with only 29% having access to improved sanitation in 2005–06, and limited improvements to 42% in 2013–14). Multivariable regression analysis using household‐level data from 2005–06 demonstrated that toilet type (TT), child stool disposal (CSD) and diet diversity (DD) were independently associated (p<0.05) with nutritional outcomes; drinking water or breastfeeding were not. The effects of DD and TT indicators are not independent, though; better DD and access to improved toilets together were significantly associated (p<0.05) with better nutritional outcomes. Also, improved DD was protective for HAZ and WAZ where TT was unimproved.ConclusionUsing data from 2005–06, our regression analyses demonstrate a positive synergistic effect of better complementary feeding and better toilets for all anthropometric indicators, but not for improved drinking water or better ways of disposing child stools. Importantly, optimal IYCF was protective against poor sanitary conditions for most outcomes. Factsheets from recently completed national surveys, for which raw data are not yet in public domain, indicate that neither IYCF practices nor sanitation have improved substantially over time in India, and that the rate of decline in undernutrition over time has also been slow. In light of these limited changes in significant determinants of undernutrition, our regression results imply that it remains urgent to jointly address IYCF and sanitation simultaneously as part of actions to improve nutrition in India, a country that carries the world's largest burden of child undernutrition.