Inequitable nutritional impact of India's first COVID-19 lockdown: a national cross-sectional analysis

India's first nationwide COVID-19 lockdown in March 2020 disrupted food systems, healthcare access, and livelihoods, raising concerns about its impact on nutritional outcomes. While the effects of the pandemic on food security have been widely documented, national-level evidence on nutritional status, particularly across economic strata, remains limited.

We analyzed data from India's fifth National Family Health Survey (NFHS-5), a national household survey conducted between 2019 and 2021, during which the COVID-19 lockdown occurred. We assessed underweight status (Body Mass Index (BMI) < 18.5 kg/m²) in adults, wasting (weight-for-height z-score < -2) in children under five, and anemia in men, women, and children under five. Outcomes were analyzed by wealth quintile (Q1-Q5). Adjusted prevalences were estimated by marginal standardization. Survey-weighted multivariable logistic regression models were used to examine associations between lockdown period and outcome prevalence, and concentration indices and curves were applied to assess changes in economic disparities.

After adjustment, underweight prevalence among men increased only in the near-poor second quintile (adjusted Odds Ratio (aOR) 1.25, 95% Confidence Interval (CI) 1.12-1.40) and declined in the wealthiest, while among women it declined in the wealthier quintiles and overall and was largely unchanged among the poorest. Wasting declined across all wealth quintiles in children, with smaller reductions among the poorest. Anemia declined across all groups. All outcomes remained concentrated in the poorest quintiles in both periods. Concentration indices and curves confirmed widening disparities in underweight and wasting, with smaller or less consistent shifts for anemia.

Following India's first COVID-19 lockdown, undernutrition improved for most groups, but these gains were inequitably distributed: improvements were concentrated among wealthier households while the poorest improved least, and near-poor men experienced a rise in underweight. Anemia declined across all groups but remained highest in the lower wealth quintiles. These estimates should be interpreted with caution, as the cross-sectional design precludes causal inference and higher mortality among the most vulnerable during the lockdown may have rendered post-lockdown estimates conservative. These findings point to the need for equity-focused interventions and resilient nutrition systems to protect at-risk populations during and after crises.