By grouping adolescents with adults, India’s surveys are routinely misestimating their health

India routinely misestimates thinness, overweight and stunting among adolescents because official data sources do not gather sufficient data specifically on adolescents, clubbing them instead with data on adults. This holds true across states, rural-urban residence and wealth groups, a June 2020 study says, showing up data gaps with wide-ranging implications for policy and programme design.

The key National Family Health Survey does not collect health and nutrition data for school-age children (6-year to 9-year-old) and early adolescents (10-year to 14-year-old), and does not separately categorise adolescents as 10-year to 19-year-olds, as suggested by the World Health Organization, the study says.

Other large-scale household health surveys conducted for the Ministry of Health and Family Welfare health ministry also have few or no data on these age groups, our analysis has found. These surveys collect data on a broad range of health and related indicators for infants and pre-school children (0 to 5-year-old), for late adolescents (15-year to 19-year-old), and for adults.

Data on late adolescents, however, are clubbed with those of adults in the National Family Health Survey. Thus parameters used to assess adult nutritional status are used to assess undernutrition or overweight for adolescents aged 15-year to 19-year-old, leading to over-estimations of thinness, even as stunting remains undetected because no parameter examines adult stunting.

These data gaps were laid bare by another health ministry survey in 2019, which pointed out that tracking health and nutrition outcomes through school-going age (6-year to 9-year-old), and early and late adolescence is crucial to ensuring that nutritional deficiencies in childhood do not persist into adulthood.

Children gain up to 50% of their adult weight and skeletal mass and more than 20% of their adult height during adolescence, so they must get adequate nutrition and care. Adolescent underweight and overweight are also among the indicators used by the Global Nutrition Report to track countries’ progress on malnutrition.

Besides, nutrition tracking must also be sex-specific, as girls are more likely to be under-nourished, according to a report by the Food and Agriculture Organization. This is particularly important in cases of child marriage and under-age pregnancy, as malnourished mothers give birth to under-nourished children.

Every second Indian teenage girl was underweight and 52% were anaemic, a survey conducted by the Naandi foundation among 74,000 girls aged 13-year to 19-year-old in 2018 found, as IndiaSpend reported in October 2018.

Besides its implications for individual health, adolescent wellbeing is also “key to achieving India’s demographic dividend”, wrote Manoj Jhalani, then the mission director for National Health Mission. India has 253 million adolescents, about a fifth of its projected population of 1.34 billion for 2020. India’s working-age population at 688 million still exceeds its dependent population–the so-called demographic dividend.

Yet, few programmes target nutrition services towards adolescents in India, experts told us. The mid-day meal scheme is also only for school-going children aged between six-year and 13-year, excluding adolescents aged 14-year and older.

The central government’s Rashtriya Kishor Swasthya Karyakram launched in 2014 has seen sporadic implementation six years on as IndiaSpend had reported earlier. Iron-folic acid tablets are distributed only to adolescent girls, and not boys, who are also malnourished, other surveys have found.

“We have a lot of information on nutritional status of children under-five in India,” said Anurag Bhargava, a co-author of the study, which suggests a continuing high burden of malnutrition in our young with low height-for-age (stunting) in 38% and low weight-for-age (underweight) in 35% of children under five. “Information on adolescent nutrition is however scant,” he added.

National Family Health Survey has health data on boys and girls only in the 15 years to 19 years age group, but clubs them with adults and has applied body-mass cutoffs inappropriate for this age group, he said. “While the brain attains 95% of its adult size by 6 years of age, memory, emotional processing, decision-making, and higher executive functions develop during mid-childhood and adolescence,” the study said, citing a February 2018 study published in The Lancet medical journal.

National Family Health Survey

National Family Health Survey is a periodic, large-scale health and demographic household-level survey that provides key data on which the health ministry and other agencies base their policies and programmes.

It collects health and nutrition indicators such as mortality rates, childhood diseases such as diarrhoea and access to immunisation, and malnutrition indicators such as stunting (height for age), wasting (weight for height) and underweight (weight for age) for children till age five.

Indicators such as body mass index, blood sugar levels and hypertension are available for adults. Crucial indicators such as body mass index are not separately assessed for children aged six to nine and adolescents aged 10 years to 19 years. In the recently released National Family Health Survey-5 (2019-2020) reports, anaemia prevalence for 15-year to 19 year-olds has been listed separately, though the data for 6-year to 14-year-olds are still missing.

“Children and adolescents of these ages are increasingly experiencing anaemia, micronutrient deficiencies, diabetes, chronic kidney diseases, cardiovascular diseases like hypertension and cancer,” Madhavi Bhargava, the lead author of the study, told IndiaSpend. “If undetected at adolescence, these will impact the health and well-being of the adult.”

Incorrect estimates of thinness, stunting

The National Family Health Survey does not use age and sex-specific reference for adolescents, as recommended by the WHO, to estimate their nutritional status, leading to an overestimation of thinness while stunting has remained undetected despite being prevalent across states, the study, which was led by a team of researchers at the Yenepoya Medical College and Research Centre in Mangalore, found in March 2020.

The prevalence of thinness in boys and girls thus estimated is 58.1% and 46.8% in National Family Health Survey-3, and 45% and 42% in National Family Health Survey-4, respectively. The study used WHO-recommended age- and sex-specific references to find that 22.3% of boys and 9.9% of girls were too thin in 2005-2006 and 16.5% and 9% in 2015-2016 – lower than National Family Health Survey estimates.

This means that 15-year to 19-year-olds are not as thin as the average for the 15-year to 49-year-old category suggests, said Madhavi. “The problem lies within our definition of adolescents while collecting this data; 15-year to 19-year-olds are considered adults and 5-year to 14-year-olds have no mention.” Though Indians are legally considered adults at age 18 for purposes such as voting, this is not the same as adulthood according to the life cycle, which is the basis of health policies and begins at 20 years.

On the other hand, stunting, another important metric for malnutrition in 15-year to 19-year-olds, has remained hidden in the data of National Family Health Survey-3 and -4. “Stunting was found in more than 30% in boys and girls in National Family Health Survey-4, with a disturbing increase in National Family Health Survey-4 compared to National Family Health Survey-3,” said Anurag Bhargava. Stunting can also complicate estimates of both thinness and overweight in children and adolescents.

Around two-thirds of the working population in India are earning 13% less because of stunting in childhood – being excessively short for their age – one of the world’s highest such reductions in per capita income, IndiaSpend reported in 2018.

Other surveys

The Comprehensive National Nutrition Survey conducted between 2016-2018 by the Ministry of Health and Family Welfare along with the United Nations Children’s Fund and international health and development research group Population Council, collected nutrition data for 6- to 14-year-olds for the first time. The Comprehensive National Nutrition Survey estimated the prevalence of malnutrition, anaemia, micronutrient deficiencies and biomarkers of non-communicable diseases in preschoolers (0 to 4-year olds), school-age children (5-year to 9-year olds) and adolescents (10-year to 19-year-olds).

“Previous national surveys had not collected nationally representative data on children between the age of 5 years and 14 years,” Comprehensive National Nutrition Survey noted in the 2016-2018 report while explaining its purpose.

Comprehensive National Nutrition Survey was the largest micronutrient survey ever conducted – it interviewed 1,12,316 children and adolescents and collected their anthropometric measures. It collected blood, urine and stool samples from 51,029 children and adolescents, across 30 states (including the National Capital Territory of Delhi) covering rural and urban households.

The data were analysed at the state and national level across the urban/rural, male/female and slum/non-slum (only for Delhi, Mumbai, Chennai, Kolkata) domain. Data were collected from three target population groups – pre-schoolers (0 to 4-year-olds), school-age children (5-year to 9-year-olds) and adolescents (10-year to 19-year-olds). A minimum sample size of 1,000 for anthropometric and 500 for biochemical indicators was fixed for each age group in each state.

But the CNNS survey was a one-off, said Madhavi Bhargava, “The document does not say if it will happen again. We need regular and periodic estimates for adolescents like we get for children and adults from the National Family Health Survey.”

The National Family Health Survey covers a wide range of data, as explained earlier, across each Indian state and Union Territory, and produces indicators at the district, state/Union Territory, and national levels, as well as separate estimates for urban and rural areas in 157 districts, and separate estimates for slum and non-slum areas in eight cities.

Other national surveys, such as the Annual Health Survey 2012-2013, District Level Household Survey 2012-2012, Coverage Evaluation Survey 2009 and data collected by the National Nutrition Monitoring Bureau in 2012 – have also not collected data for the 5-year to 19-year-old age group, separately, for several important health indicators.

Nutrition data availability and gaps

The Comprehensive National Nutrition Survey has data on several indicators including stunting, wasting, underweight, overweight or obesity, body mass index, anaemia, blood sugar levels and hypertension, among others, for adolescents.

But it also has no data on adolescent sexual behaviour, sexual health, maternal health, teenage pregnancies, early child-bearing and diseases such as HIV, which are important indicators of adolescent health and wellbeing, United Nations International Children’s Emergency Fund said in A report on adolescents published in April 2012. It also does not have data on substance use and abuse and its impact on adolescent health.

“Indicators like teenage pregnancies and substance abuse are important for adolescents,” said Madhavi Bhargava. “So is mental health but Comprehensive National Nutrition Survey is not a comprehensive health survey, it is a national nutrition survey. We do not have data-based information on these issues even though we have programs like Rashtriya Kishor Swasthya Karyakram working for adolescents on these very issues.”

Policy neglect

As a result, adolescent nutrition has witnessed severe policy neglect, as a majority of nutrition funds and programmes have been focused on children between 0 to 5 years or pregnant women.

Although the first 1,000 days (roughly two years of age) get much attention, the next 7,000 days (up to 19 years) offer opportunities to catch up, and adolescence is the last window of opportunity, said Anurag Bhargava, adding, “Our data suggests that we are losing that opportunity.”

More than 33% of the disease burden and almost 60% of premature deaths among adults can be associated with behaviours or conditions that begin or occur during adolescence, according to a 2014 report by the WHO.

“Stunting is a major indicator of malnutrition, despite which stunting in adolescents has received less attention as a public health problem,” Anurag Bhargava said. “The lack of nutritional support for adolescents, especially adolescent girls, leads to intergenerational malnutrition when a stunted and malnourished mother gives birth to a malnourished low-birth-weight child.”

Inadequate programmes

The result of insufficient information on early adolescents has been inadequate programmes to target them, experts told us.

“Not enough programmes are functioning in India to look after adolescent nutrition,” said Yogendra Ghorpade, field coordinator of TANDA, a field action project at the Tata Institute of Social Sciences. “Mid-day meals are not provided to children after class 8 [age 13 years onwards], a few states distribute iron-folic acid tablets to adolescent girls through the Integrated Child Development Services or Anganwadis, but this is neither available everywhere, nor does it include adolescent boys who are also malnourished. The few places where these services were available, have also been very inconsistent ever since the lockdown started.”

The Ministry of Health and Family Welfare launched the Rashtriya Kishor Swasthya Karyakram, or National Adolescent Health Programme, in 2014 to address nutrition, reproductive health, substance abuse, mental health and other issues concerning adolescents. Adolescent friendly health clinics were set up in every state and Union territory except Lakshadweep, to provide clinical and counselling services on diverse adolescent health issues through trained service providers at Adolescent friendly health clinics, located in community health centres, district hospitals and medical colleges.

But this programme has not been functioning well. “Even when specifically targeted programmes are designed for adolescents and their needs, their beneficiaries remain few because we know so little about this age group,” said Ghorpade, “For instance, if we can’t map the trends of teenage sex, pregnancy and uptake of family planing services in the age group, how can we even begin to design programmes to address these needs?”

“Programmes like Rashtriya Kishor Swasthya Karyakram are just skimming the surface because we do not know the extent of the problems we are trying to tackle,” said Anjani Kumar Singh, programme manager, Vatsalya, an NGO working on child-rights, nutrition and health in Uttar Pradesh. “The uptake of services is scanty when the design of programmes is poor.”

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.