Measuring malnutrition in all its forms: An update of the net state of nutrition index to track the global burden of malnutrition at country level

Abstract

BackgroundThere is an urgent need for tools to better understand and measure the nutrition challenges identified in the Sustainable Development Goals. Proposed updates to the existing Net State of Nutrition Index (NeSNI) do better at highlighting the multi-dimensional nature of malnutrition (undernutrition, overweight, and micronutrient deficiencies) that can occur simultaneously within a country and allows for nations to be ranked based on complex burden of malnutrition as well as monitoring change over time for multiple issues simultaneously. MethodsNeSNI was developed in 2015 based on the six World Health Assembly (WHA) nutrition targets set in 2011, using a standard algorithm for developing a Human Development Index. We updated the original NeSNI by i) using the most recent national survey data available today, ii) developing a new variant of the original index by adding female adult overweight as a 7th indicator (NeSNI-Double Burden), and iii) exploring the value of adding pre-schooler vitamin A deficiency (VAD) as an 8th indicator to create a “NeSNI-Triple Burden” index. The aim of adding further indicators was to enhance the original index by better capturing additional important dimensions of “malnutrition in all its forms”. ResultsIn 2019, the top-ranked nations, indicating the least burden of malnutrition using the original six WHA nutrition indicators (n = 89 countries), were Uruguay, Costa Rica, and Colombia. At the bottom of these rankings were India, Pakistan, and Yemen. The greatest improvements, based on positive rank change between 2015 and 2019, were made by Kenya, Belize, and Kazakhstan. The addition of female adult overweight to the original index (NeSNI-Double Burden, n = 123), and the addition of VAD in preschool-age children (NeSNI-Triple Burden, n = 46), had a significant impact on country rankings, with Rwanda moving to 1st place in both of the new indexes. ConclusionUpdating the original NeSNI with recent data shows how countries have improved or regressed over time and compared to each other. The addition of female adult overweight and VAD in preschool-age children to the original NeSNI computation yields a more holistic assessment of country-level malnutrition in all its forms. This is manifest by shifts in relative rankings of countries depending on the addition or subtraction of elements in the index. Such analyses highlight the importance of having robust tools to measure nutrition indicators that are sensitive to need and to new data over time. Adoption of an expanded index to include female adult overweight and pre-schooler VAD allows policy makers to better tailor policies and interventions to actual and changing need, to track changes in the burden of malnutrition over time, and to measure the success of investments and programs implemented in the name of improving nutrition.