# Risk factors for the intra-individual double burdens of malnutrition among reproductive-age women in India: a secondary analysis of three rounds of the National Family and Health Survey

## TL;DR

This study examines the risk factors for co-occurring malnutrition issues like underweight and anaemia or obesity and anaemia among Indian women of reproductive age.

## Contribution

The study identifies distinct sociodemographic and environmental risk factors for two types of intra-individual malnutrition double burdens in India.

## Key findings

- 11% of women had the underweight-anaemia double burden, while 21% had the overweight/obesity-anaemia double burden in 2019–2021.
- Underweight-anaemia was most common in central India, while overweight/obesity-anaemia was prevalent in northern, southern, and coastal districts.
- Environmental factors played a significant role in the co-occurrence of malnutrition, as shown by AUC statistics.

## Abstract

Underweight, overweight/obesity and anaemia are prevalent among reproductive-age women in India, but factors affecting their intra-individual co-occurrence are unclear. Our objectives were to examine the prevalence, spatial distribution and risk factors for concurrent ‘double burdens’ of anaemia with underweight or overweight/obesity within the same individual.

Using data from reproductive age women (15–49 years) in the Indian National Family Health Surveys 2005–2006, 2015–2016 and 2019–2021, we calculated the national prevalence of the intra-individual double burdens of malnutrition and mapped their district-level distributions. We examined the association of 28 potential risk factors with anaemia, underweight, overweight/obesity and their co-occurrence using multilevel logistic regression and calculated area under the curve (AUC) statistics.

The underweight-anaemia double burden affected 11%, and overweight/obesity-anaemia double burden affected 21% of women in 2019–2021. Overweight/obesity-anaemia was prevalent in northern, southern and coastal districts, while underweight-anaemia was most prevalent in central India. For underweight-anaemia, important risk factors were tobacco consumption, younger age, lower education, lower household wealth, scheduled tribe background, larger household size, region and living in a high malaria transmission area. For overweight/obesity-anaemia, risk factors included older age, being educated, higher household wealth, region and living in an area with more hot days than average in recent years. AUC statistics showed a significant role of environmental factors.

The double burdens present significant public health challenges for India. The spatial and sociodemographic distinctness of the burdens suggests the possibility of evidence-informed targeting of programmes.