By 2050, two-thirds of the world’s population is projected to be urbanised (Fan 2017). Parallelly, a small prognostic body of literature highlights malnutrition as an imminent urban challenge (Vilar-Compte et al 2021; Knorr et al 2018; Diekmann et al 2018) further compounded by the outbreak of COVID-19. In low- and middle-income countries, the urban poor are the most hit by the food insecurity impacts of COVID-19 (Welsh 2021). Poverty is estimated to increase by 15% in rural areas but by 44% in urban areas in sub-Saharan Africa due to COVID-19 outbreak (Laborde et al 2020). Overall, an estimate covering 118 countries suggests a 14.3% increase in the prevalence of wasting among children below five years due to COVID-19 (Heady et al 2020). These increases are primarily due to declining income and rising food prices (Smith and Wesselbaum 2020). Across countries like Bangladesh, Burkina Faso, Ghana, Nepal and Sierra Leone among others, widespread drops in employment and income were observed and by April 2020, many households were unable to meet basic nutritional needs due to supply chain disruptions, reduced access to markets and insufficient social protection (IPA 2021).  These factors would be affecting urban households more severely because they almost entirely depend upon the market for their consumption needs. Possibly, a significant proportion of increase in child malnutrition due to COVID-19, is concentrated in urban areas. As such, COVID-19 also offers a window for public policies to broaden their malnutrition agenda to include its urban dimension. The nutrition policy discourse, however, is yet to accommodate this potential shift in prevalence of malnutrition. In fact, it continues to exhibit a clear rural bias (Steenkemp et al 2021; Welsh 2021).

 

The most glaring example of this bias rests with the Sustainable Development Goals—as the global framework for action against hunger. The SDG 2 on "zero hunger" continues to treat malnutrition from a productionist perspective and neglects its urban dimension (Blesh 2019; Battersby 2017). Although SDG 11 talks about sustainable cities, SDG 2 and 11 taken together fail to produce an clear urban nutrition agenda. This itself has partly been reinforced by the lack of systematic evidence on growing urban malnutrition. Despite growing awareness towards urban nutrition challenge, an authoritative evidence on the same remains lacking. Based on an analysis of the Demographic and Health Survey (DHS) data for India, it is possible to acquire preliminary insight into the "urbanisation of malnutrition" preposition.

 

Although, the majority of India’s population still resides in rural India, there are arguments that a reasonable expansion of the definition of urbanisation would drastically increase the estimates of urbanisation in the country (Denis et al 2012). There are very limited evidence on how growing urbanisation has affected the state of hunger and malnutrition in the country. However, these evidences indicate that nutrition and food consumption are affected by urbanisation rate in India (Sendhil et al 2020, Pandey et al 2020, Nie et al 2019) with prevalence of high child malnutrition among urban poor (Huey 2019, Murakar et al 2020,). Though there are also claims of rising over-nutrition, published global data shadows the notion that India might have an obesity endemic and India, in fact, has the lowest obesity level in the world (Sathyamala 2016). Urban malnutrition in India has been further exacerbated by COVID-19, with greater decline in nutritional quality and quantity among urban poor as compared to rural counterparts (Kapil 2021). These evidences do put forth a sound basis for a detailed inquiry into the state of urban hunger and malnutrition in the country.

 

This paper attempts to navigate into this unexplored terrain and reflect upon the question of whether urban India is undergoing a decline in nutrition advantage or is experiencing an increase in malnutrition burden. As a clarification, the paper does not intend to establish any causality underlying child malnutrition in urban areas, but choses to analyse the status in this regard.

 

Data and Methodology

 

The data for the analysis has been obtained from the first (1992-93), second (1998-99), third (2004-05), fourth (2015-16) and fifth (2019-20) rounds of theDHS for India. DHS fifth round data is not yet released for all the states of India and where available they have been utilised for analysis. Population data has been obtained from the Census of India conducted in 2001 and 2011. The paper focuses on child malnutrition as measured by three anthropometric indicators: stunting, underweight and wasting, respectively defined in terms of height–age ratio, weight–age ratio and height–weight ratio of a child (WHO 2010).

 

The analysis has been done through descriptive techniques, enabling methodical disaggregation of data across time and space, which helps in arriving at salient stylised facts. Since the objective is to describe and acquire preliminary understanding into the state of urban child malnutrition, a descriptive rather than inferential approach is appropriate here.

 

Results and Discussion

 

India and her diminishing urban nutrition advantage

In 2015-16, the prevalence of stunting, underweight and wasting among children aged 0-5 years in urban India was lower than in rural India (Table 1). The prevalence of child malnutrition, except wasting declined between 2005-06 and 2015-16 for both rural and urban India.  However, the decline in urban India was less than that in rural area. While the prevalence of stunting declined in rural India by 6 percentage point, in urban India, it declined only by 1.4 percentage points. Similarly, rural underweight declined by 7.7 percentage points whereas urban underweight declined by 4.1 percentage points. Although the prevalence of wasting increased as a whole, the increase for urban India was relatively higher.

 

Table 1: Percentage Prevalence of Malnutrition Among Children Aged 0-5 years in Urban India and Changes in Percentage Point and Absolute Terms

	Percentage Prevalence (2015-16)		Percentage Prevalence (2004-05)		Decrease (in percentage point)		Decrease (in absolute numbers) *
	Rural	Urban	Rural	Urban	Rural	Urban	Rural	Urban
Underweight	38.3	29.1	46	33.2	7.7	4.1	1,31,41,177	4,09,608.9
Stunting	41.2	31	47.2	32.4	6	1.4	1,12,48,843	-6,72,056
Wasting	21.5	20	21	17	-0.5	-3	12,77,919	-7,70,931

Source: Based on DHS (2004-05) and (2015-16). 

*Using child (0-5 years) population from Census of India 2001 and 2011.

 

 

Declining urban nutrition advantage is also apparent from Figure 1 depicting the percentage point decline in malnutrition among children of 0-3^[1] years in India since 1992-93. It is discernible that between 1992-93 and 1998-99 and until 2004-05, the decline in child malnutrition in urban India was higher than that in rural India. However, after 2004-05, decline in child stunting and underweight in rural India overtook urban India. Alongside, the increase in the prevalence of wasting was higher in urban  than in rural areas. Corresponding to the rural edge in reducing child malnutrition—a reflection of village-centric interventions, the diminishing urban nutrition advantage has been also fuelled by urban population growth.

 

Figure 1 

 

 

The trend of declining urban nutrition advantage is also observable among the states. The percentage incidence of urban stunting and wasting among children aged 0-5 years in states of India during 2004-05, 2015-16 and 2019-20 is given in Table 2.  Mirroring the national picture, incidence of child stunting in urban areas of all states is lower than that in their rural areas in 2015-16, except Kerala and Punjab. Incidentally, Kerala  witnessed the sharpest increase in urbanisation between 2001 and 2011. Between 2005-06 and 2015-16, most states have witnessed a decline in child stunting in both rural and urban areas (Table 2). Percentage point decline in urban child stunting is the sharpest in Maharashtra, Gujarat and Uttar Pradesh, along with several north-eastern states between 2005-06 and 2015-16. During this period, the decline in urban stunting in Jharkhand, Goa, Rajasthan, Kerala and West Bengal is marginal. Further, in 18 out of 28 states, percentage point decline in stunting in rural areas has been greater than urban areas. By 2019-20, the rural–urban gap in the incidence of child stunting appears to have narrowed down. In 2019-20, incidence of child stunting in urban areas of several states (for example, West Bengal, Maharashtra and Jammu and Kashmir) is higher or at level comparable to rural areas.

In terms of wasting among children, six states, including Bihar, Himachal Pradesh, Jammu and Kashmir, Goa, Kerala and Uttar Pradesh have higher incidence in urban areas as compared to rural areas, as in 2015-16. Except Bihar, Madhya Pradesh, Tamil Nadu and most of the north-eastern states, all other states have witnessed a percentage point increase in urban wasting during 2005-06 and 2015-16. The data on wasting present a clear rural bias. Percentage incidence of urban wasting has increased in 18 states of India as compared to rural wasting, which increased in only three states. Even in Maharashtra—the state being lauded for its successful nutrition intervention (Nisbett and Barnett 2017)—wasting in urban areas has increased by around 11% between 2005-06 and 2015-16. This has led to higher levels of urban wasting than rural wasting in several states including Bihar, Goa, Himachal Pradesh, Jammu and Kashmir, Kerala and Uttar Pradesh. Incidence of urban wasting in these states (except Uttar Pradesh for which data is not available yet) has declined slightly afterwards and is marginally lower than rural wasting in 2019-20. Between 2015-16 and 2019-20, incidence of urban wasting has increased in Andhra Pradesh, Assam, Bihar, Jammu and Kashmir, Manipur, Mizoram, Nagaland, Tripura and West Bengal. In 2019-20 several states have higher or comparable incidence of child wasting in urban areas than rural areas; for example  Andhra Pradesh, Himachal Pradesh, Kerala, Sikkim, West Bengal. These trends show that for India as well as the states, there has been a decline in urban nutrition advantage.

 

The Increasing Urban Malnutrition Burden

As the share of the urban in total population increases, the relatively lesser decline in malnutrition in urban areas would imply the addition of relatively greater number of malnourished children to urban areas as compared to rural areas. Table 1 also gives changes in malnutrition levels in India, in absolute terms. The number of malnourished children in 2005-06 and 2015-16 is estimated using child population data obtained from the census of India 2001 and 2011, respectively. Although this would be a conservative estimate as population would increase between both 2001-05 and 2011-15, the fact that sampling for DHS data is based on the nearest census data as the reference, justifies the estimation. The exercise has not been done for 2019-20 because entire data from DHS-V is not released yet.

 

Between 2001 and 2011, the size of child population in rural India declined by 88,84,983 while in urban India it increased by 38,54,656. The addition to urban child population is also reflected in absolute increase in number of stunted and wasted children in urban India (Table 1). The number of stunted children in urban India increased by 6,72,056 even though in percentage terms the incidence of stunting in urban area declined by 1.4%. Alongside, the size of wasted children in urban India has increased by 7,70,931. Notably, the number of wasted children in rural India declined by 12,77,919 even though the percentage incidence of wasting in rural India has increased by 0.5%. Thus, the first point when looking at the gravity of urban malnutrition, is to look at it in absolute rather than in proportional terms. Irrespective of the percentage incidence of child malnutrition in urban India, the number of children who are suffering from malnutrition is increasing.

 

Table 3: Absolute Change in Child Malnutrition between 2004-05 and 2015-16

 

	Stunting		Wasting
	Rural	Urban	Rural	Urban
Andhra Pradesh	15,811,70	1,58,937.8	-28,007.3	-1,57,106
Arunachal Pradesh	23,328.25	5877.456	-20,619.3	-6280.4
Assam	4,27,311.2	44324.05	-1,47,874	-818.752
Bihar	4,61,120.2	8695.074	7,65,699.3	8939.775
Chhattisgarh	5,65,810.8	5490.784	-65,810.5	-39674.8
Goa	9191.59	17.978	6467.235	-15,266.2
Gujarat	7,91,156.7	2,56,554.8	-3,00,285	-2,55,729
Haryana	4,29,562.4	-22,049.3	26,138.13	-71,316.4
Himachal Pradesh	1,02,405.5	3354.17	53,014.03	-2680.04
Jammu and Kashmir	-7702.91	-15,263.8	13,966.18	-33110.1
Jharkhand	1,56,308.5	-35825.8	1,85,721.1	-54671.8
Karnataka	6,73,802.5	-2995.6	-2,52,650	-2,36,806
Kerala	3,93,660.5	-10,2254	2,57,807.6	-1,53,734
Maharashtra	1,304,633	6,45,037.7	-3,92,463	-6,11,306
Manipur	9233.728	-1457.45	3402.117	146.964
Meghalaya	7811.028	8445.754	54,481.93	5660.194
Mizoram	8506.905	1979.041	245.982	1931.099
Madhya Pradesh	8,27,982.6	1,32,449.4	8,86,436.4	2,30,920.2
Nagaland	33,445.72	-1184.05	8954.631	-2117.16
Odisha	66,7636.3	42,609.57	70,824.96	-22,390.5
Punjab	3,68,180.6	53,995.62	-1,02,100	-71,008.5
Rajasthan	59,8611	-849.723	-1,77,858	-40,665.3
Sikkim	12,323.06	-1095.88	-505.073	-901.736
Tamil Nadu	3,31,265.4	1.09,751.4	2,19,545.1	20,312.28
Tripura	45,630.95	2967.293	33,907.52	831.965
Uttar Pradesh	3,522,550	6,27,185.1	-2,43,967	-28,3561
Uttarakhand	2,13,333	-37,435.1	38,903.43	-34,234.2
West Bengal	1,842,501	-48280.3	-4426.71	-1,06,795
India	16,054,722	2.166.477	1,277,919	-18,91,405

 

The states where number of stunted children in urban areas has increased include Haryana, Jammu and Kashmir, Jharkhand, Karnataka, Kerala, Manipur, Nagaland, Rajasthan, Sikkim, Uttarakhand and West Bengal (Table 3). Furthermore, the decline in thr number of stunted children in urban areas has been meagre in Bihar, Chhattisgarh and Goa. Thus, relative urban disadvantage in the decline in the number of stunted children is apparent in majority of states of India. However, a clear rural bias in absolute as well as proportional decline is discernible for child wasting.

Except Tamil Nadu, Bihar and most of the north-eastern states, number of wasted children has witnessed considerable increase over 2005-06 and 2015-16 (Table 3). Alongside, 11 states have also witnessed an increase in the number of wasted children in their rural areas, but the urban addition is usually higher than rural addition of those children. Maharashtra—the state accounting for the largest share in urban population of India—has witnessed the greatest addition of wasted children to its urban areas. Except Bihar and Madhya Pradesh, all other states of India have witnessed an increase in absolute size of malnourished children in terms of all or at least one of the malnutrition indicators. Urban areas of nine states of India including Kerala, Karnataka, Jharkhand and Rajasthan have witnessed an increase in absolute number of malnourished children—simultaneously in terms of stunting as well as wasting between 2005-06 and 2015-16.  These states are at higher risk to the extent stunting and wasting overlaps among children. This is because higher mortality has been reported when children are both wasted and stunted (with low height-for-age) (McDonald et al 2013). Further, if the child continues to be wasted, it is very unlikely that they will be able to escape the probability of staying stunted.

 

Two observations can be made from the above trends. One, while child stunting is largely concentrated in rural areas, an urban shift in the same is apparent in several states, at least in absolute terms. Two, wasting among children is urbanising faster. In fact, the picture on child wasting is discouraging, as it has increased in proportional as well as absolute terms in many states including Kerala, a state that has been India’s role model in battling malnutrition. Maharashtra also gives a discouraging picture on child wasting though the state has witnessed sharp decline in child malnutrition in recent period..

Table 2: Percentage incidence of rural and urban child malnutrition in states of India

 

	2019-20				2015-16				2004-05
	Wasting		Stunting		Wasting		Stunting		Wasting		Stunting
	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural
Andhra Pradesh	17.6	15.5	23.1	34.2	15.5	17.8	28.3	32.5	10.8	13.3	37.2	45.7
Arunachal Pradesh					24	30.7	24	30.7	7.8	17.7	40.8	43.7
Assam	19.1	22.1	29.8	36.0	13.2	17.5	22.3	38	14.2	13.8	35.6	48.2
Bihar	21.6	23.1	36.8	43.9	21.3	20.8	39.8	49.3	26.1	27.8	48.2	57.1
Chhattisgarh					20.6	23.7	31.6	39.2	18.3	20.7	39.3	57
Goa	17.7	21.5	24.3	28.2	27.7	11.5	18.3	23.2	11.9	17.5	21.4	29.9
Gujarat	22.4	26.7	32.4	43	23.4	28.5	31.7	42.9	16.5	20.3	47	55
Haryana					21	21.3	33.4	34.3	17.6	20.3	38.7	48.3
Himachal Pradesh	16.2	17.6	27	31.3	19.1	13.3	21.4	26.7	15.2	20	27.2	39.6
Jammu and Kashmir	17.6	19.4	30.1	25.9	16.1	11	23	28.8	12.3	15.6	29.4	37.2
Jharkhand					26.8	29.5	33.7	48	24.9	35	35.2	53.4
Karnataka	18.5	20.1	32.2	37.2	24.8	26.9	32.6	38.5	17.1	18.6	36.2	47.6
Kerala	16	15.5	20.1	26.4	16	15.5	19.8	19.5	10.5	18.5	22.4	25.7
Maharashtra	23	27.3	34.9	35.5	24.9	26.1	29.3	38.4	14	18.4	42.5	49.4
Manipur	9.8	10	20.1	25.1	6.4	7.1	24.1	31.4	8.6	9.2	29.7	38.2
Meghalaya	13	12	35.1	48.2	13.7	15.6	36.5	45	24.3	32.2	54.9	55.6
Mizoram	8.3	11.2	25.5	31.9	4.5	7.8	22.7	33.7	8.3	9.2	29.6	49
Madhya Pradesh					22	27.1	37.5	43.6	32.6	36.6	44.4	51.8
Nagaland	21.7	18.2	27.1	34.7	10.1	11.7	22.5	30.9	10.6	14.1	30.9	41.3
Odisha					17	20.9	27.2	35.3	14.6	20.8	35.2	46.8
Punjab					15	16.1	27.6	24.5	9.1	9.1	35.3	37.9
Rajasthan					21.6	23.4	33	40.8	20.9	20.6	34.9	46.5
Sikkim	13.2	13.9	15.1	25.6	13.2	14.7	22.9	32.9	15.4	8.9	34.3	38.6
Tamil Nadu					19	20.3	25.5	28.6	21.2	22.7	31.2	32.5
Tripura	17.1	18.6	27.1	33.9	13.4	18	17.2	26.8	24.1	25.5	34.5	36.7
Uttar Pradesh					18	17.9	37.9	48.5	13.1	15.6	50.4	58.2
Uttarakhand					18.6	19.9	32.5	34	11.4	21.6	27.7	50.6
West Bengal	20.2	20.4	32.1	34.4	16.7	21.6	28.5	34	14.1	17.8	29.9	48.3
India					20.00	21.50	31.00	41.20	17	21	40	51

 

For 2019-20, data available for selected states only.

Source: DHS (2004-05), (2015-16) and (2019-20).

 

Stunting or wasting? Varying forms of malnutrition challenge for urban areas

The above analysis reflects that a spatial transition is taking place as far as the incidence of child stunting and wasting in India is concerned. Evidently, while urban India is losing its nutrition advantage, its absolute malnutrition burden is increasing alongside. Is there a potential association between level of urbanisation and incidence of child malnutrition? If so, what is the direction of this association given that urban areas continue to have lower child malnutrition than rural areas?

 

 

  

Figure 2: Scatter fit between level of urbanization (2011) and change in incidence of urban malnutrition (stunting(a, b), and wasting(c)) between 2005-06 and 2015-16

Source: Based on DHS (2004-05) and (2015-16) and Census of India 2011

Figure 3: Lorenz curve for states’ share in wasted children against states’ share in urban population of India

Source: Based on DHS (2015-16) and Census of India 2011

 

Figure 2 plots percentage point change in incidence of urban stunting and wasting across states of India between 2005-06 and 2015-16 against their levels of urbanisation (in terms of share of urban population in total population) in 2011. From Figure 2a on percentage point change in urban stunting, Maharashtra and Gujarat appear to be outliers due to significant reduction^[2] in their urban stunting levels during this period. Figure 2b redraws the graph excluding these two outliers. As seen, the relationship between the change in urban stunting and the level of urbanisation is represented well through a quadratic fit, explaining about 14% of variation in change in stunting level. Figure 2c plots percentage point changes in incidence of urban wasting among children aged 0-5 years during the same period, again with a quadratic fit. What appears to have happened in recent years in Indian states is that the rate of decline in incidence of child malnutrition has displayed a trend inverse to the level of urbanisation. That is the higher the share of urban population in a state, the lower is the rate of decline in urban malnutrition in that state. This relationship in case of urban wasting is largely accounted for by more urbanised states of India, that is, Maharashtra, Karnataka, Goa and Kerala. These four most urbanised states have witnessed increase in urban wasting in proportional as well as absolute terms.

Two additional observations can be made from figure 2.  One, the inverse trend between the level of urbanisation and the decline in incidence of urban stunting is more apparent as we shift from low to medium level of urbanisation, and two, the decline in wasting becomes steeper as we move from medium to higher level of urbanisation. Thus, urban stunting declined relatively slowly in states with low to medium level of urbanisation and urban wasting declined less for states with relatively higher level of urbanisation. From the data here, it appears that urban stunting is likely to be a challenge for states at early stage of urbanisation while for rapidly urbanising states, urban wasting is the concern.

As per DHS (2015-16), urban centres like Chennai, Hyderabad and Delhi have wasting levels between 14%–19% . In Bengaluru, Mumbai and Ahmadabad it is as high as 25% to 27%, which is alarming. Wasting among children is associated with high mortality and morbidity risks as well as low linear growth (Black et al 2008; McDonald et al 2013). Any success in combating stunting among children may not be sustainable in the absence of decline in wasting since there is evident association between highly variable weight–height ratio and lower linear growth (Black et al 2008).

 

The fact that more urbanised states are harbouring majority of wasted population of urban India is further substantiated from Figure 3 that depict Lorenz curve between states’ share in India’s urban population on one hand and their share in the wasted children of urban India on the other. There is considerable gap between the line representing states’ share in wasted children of urban India and the line of equality in Figure 3. States accounting for the bottom 50% of urban population of India have a share of less than 10% in wasted children of urban India. Top 20% of the most urbanised states in India (in terms of population) account for nearly 40% of wasted children of urban India. Similarly, top 30% of the most urbanised states of India account for 55% of wasted children of urban India. Figure 3 thus further confirms that more urbanised states do account for relatively greater proportion of wasted children of urban India. That is, as the states urbanise more, they also account for disproportionately high share in number of wasted children in urban India. Keeping the pieces together, it may be safely concluded that urban India is likely facing the child wasting challenge. Wasting among children reflects acute malnutrition either due to food shortage and poor diet or due to infections and poor health (Harding et al 2018; WHO 2010). Notably poor health itself is also exacerbated by inadequate diet.

 

COVID-19 as a Catalyst to Urban Malnutrition Challenge: A Note to Conclude

 

From the above analysis, it is unambiguous that urban India is facing a malnutrition challenge, especially in terms of child wasting. Though it might be early to connect this to a looming hunger crisis, growing child wasting questions the claims of food security in urban India. In fact, a studied inadequacy in food access has prevailed in India either due to rising food prices (Anand et al 2016) or declining food availability (Patnaik 2010). The scenario has worsened following food price spikes caused by supply chain disruptions during COVID-19 that affected entire urban food system (FAO 2020).  This has affected urban population more adversely because, one, they depend upon market for their consumption needs, and two, COVID-19 restrictions impacted urban livelihood activities more harshly (Welsch 2021). In several countries, reduction in household food expenditure has been found to be greater in urban areas (Kang et al 2021, Ruszczyk et al 2021). Evidently, both quantity and quality of urban food consumption has deteriorated (Ruszczyk et al 2021).  Similar evidences have been found in India as well (Sukhwani et al 2021, Kapil 2021). Multiple surveys in the countryclearly show deterioration in food security (Dreze and Somanchi 2021, Kesar et al 2021), especially among landless farmers, informal workers and migrants (Jaacks et al 2021). Again, informal workers and migrants predominate among the urban poor, surrounded by unique food entitlement systems. They have been hit harder during COVID-19, leading to rise in urban food insecurity (Kapil 2021). Although the rise in urban wasting began nearly a decade back in India, COVID-19 has certainly exacerbated the challenge.  Implications of COVID-19, if collocated with the findings in this paper, urgently call for a dedicated urban food and nutrition agenda.