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New Delhi: Undernourishment is not the only factor responsible for stunting among children—where a child’s height is low for his or her age—and with improved access to healthcare and sanitation, India can dramatically reduce the incidence of stunting, according to a World Bank report released on Thursday.

The report, titled Nutrition in India, analyses data from the 2005-06 National Family Health Survey (NFHS) and the 2011 HUNGaMA (Hunger and Malnutrition) survey to show that the rate of stunting in children with adequate feeding, healthcare and environmental health (hygiene and sanitation) is nearly half that among children who don’t get these in adequate measure—23% compared with 52%.

Even in states with poor nutrition outcomes like Bihar, Madhya Pradesh and Uttar Pradesh, the prevalence of stunting in children with adequate food, healthcare and hygiene is 30%, compared with 54% among those who are less advantaged, the report said.

Stunting is associated not only with failure in physical growth but also with impaired brain and cognitive development, the report said. The window of opportunity is narrow for arresting stunting, from conception to two years of age, it said.

The report said that height at age two is the best predictor of adult height and future human capital. In India, 48% of children under five are stunted (according to 2005-06 NFHS data), the highest among the Brics (Brazil, Russia, India, China, and South Africa) countries.

Strikingly, prevalence of stunting is high among medium- and high-income households in India. While stunting among children from households in the middle wealth quintile is 50%, it is 25% in the upper wealth quintile, the report said.

Even among the wealthiest households, only 7% of children between six months and two years of age receive adequate feeding, healthcare and environmental health (water and sanitation). While 70% of these children require adequate environmental health, only 36% receive appropriate healthcare and just 18% are fed the recommended quality and quantity of food for their age.

“The report debunks the myth that malnourishment affects only children from the poor households in the country—child care, feeding information and awareness are as important," said Onno Ruhl, World Bank country director.

“Sanitation and clean drinking water are critical too, and the present government’s focus through the Swachh Bharat Abhiyan is incredibly important," he said.

Ruhl added: “Maternal and child health is not just a matter of survival. A stunted child will grow up with lower human capital and will be a demographic risk to the country."

In India, less than 2% of children in the age group of six to 23 months have adequate feeding, healthcare and environmental health, the report said, adding that the country loses over $12 billion in gross domestic product to vitamin and mineral deficiencies annually.

“Coupled with better health, water and sanitation programmes, the Integrated Child Development Scheme (ICDS)—India’s flagship nutrition programme for children—could have a lasting impact on nutrition," said Ashi Kathuria, senior nutrition specialist and one of the authors of the report. “The first 1,000 days in the life of a child are extremely important and we must not miss that window of opportunity."

According to the NFHS 2005-06 data, 43.5% of children under five in India were undernourished. But the Global Hunger Report, released last month by the International Food Policy Research Institute, a global think-tank, said India had drastically reduced the proportion of underweight children to 30.7% in 2013-14 due to a focus on schemes like ICDS, the National Rural Health Mission, the rural jobs scheme and reforms in the public distribution system.

These improved numbers are based on the 2013-14 Rapid Survey on Children by the ministry of women and child development and Unicef, which is yet to be released by the government of India.

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