Children residing in rural areas appear particularly vulnerable to stunting, leading researchers to recommend prioritising nutritional programmes in the hilly and mountainous regions of the country. Despite numerous initiatives aimed at combating malnutrition, childhood stunting remains a significant public health concern in India, affecting more than a third of children under five years old. While studies from other countries have identified a correlation between high altitudes and increased stunting, whether this association holds in India, where a substantial portion of the population lives above 2500 metres, is still being determined. To investigate this potential link further, researchers utilised data from the 2015–16 National Family Health Survey (NFHS-4), a nationally representative survey of Indian households, including 167,555 children under five from various regions. The majority of these children (98%; 164,874) lived below 1000 metres above sea level; 1.4% (2,346) resided between 1000 and 1999 metres; and a smaller fraction (0.2%; 335) lived at or above 2000 metres. Notably, seven out of ten children lived in rural settings.
Stunting was found to be 36% overall, more prevalent among children aged 18–59 months (41%) than those younger than 18 months (27%). A higher incidence of stunting was observed in children who were third-born or later (44%) compared to firstborns (30%). Additionally, children who were notably small at birth exhibited even higher rates of stunting (45%). The education level of mothers played a significant role, as the prevalence of stunting decreased with increasing educational attainment. Children whose mothers had no schooling showed more than double the prevalence of stunting compared to those whose mothers had higher education (48% vs 21%).
Other protected factors included antenatal care, such as clinic visits, tetanus vaccinations, iron and folic acid supplementation, proximity to health facilities, and not being part of a specific caste or indigenous tribe. This observational study captures a snapshot in time and does not establish causality between altitude and stunting, as acknowledged by the researchers. However, they propose plausible explanations for their findings. For example, chronic exposure to high altitudes can diminish appetite, impair oxygen delivery to tissues, and reduce nutrient absorption.
Additionally, food insecurity is often more severe in higher elevations where agricultural yields are lower, and the climate is more severe. Similarly, delivering healthcare services, including implementing nutritional programmes and healthcare access, poses more significant challenges. The researchers conclude that a comprehensive approach involving various health and nutrition sectors is essential to tackle stunting, especially among children in vulnerable areas.
This approach should integrate reproductive health initiatives, women’s nutrition programmes, infant and young child feeding interventions, and food security measures. Ongoing research, monitoring, and evaluation are crucial to developing evidence-based policies and targeted actions that ensure every child in India has the chance for healthy growth and development. Professor Sumantra Ray, Executive Director of the NNEdPro Global Institute for Food, Nutrition and Health, which co-owns BMJ Nutrition Prevention & Health with BMJ, remarks on the need for further study.
In recent decades, public health interventions in India have effectively addressed some nutritional issues related to high altitudes, such as iodine deficiency. However, this study underscores the complexities of malnutrition in mountainous regions, where a deeper understanding of the interplay between genetics, environment, lifestyle, and socio-economic factors is needed to address malnutrition among children under five fully. The research highlights the urgent need for tailored interventions that consider the unique challenges faced by these communities, ensuring that every child has the opportunity for a healthy start in life.
More information: Santosh Bhagwanrao Phad et al, Geographical altitude and stunting among children aged under 5 years in India, BMJ Nutrition Prevention & Health. DOI: 10.1136/bmjnph-2024-000895
Journal information: BMJ Nutrition Prevention & Health Provided by BMJ Group
