National Nutrition Mission Research Articles

Utilization of Integrated Child Development Services (ICDS) and its linkages with undernutrition in India.

The Integrated Child Development Services (ICDS) programme has been the central focus of the POSHAN Abhiyaan to combat maternal and child malnutrition under the national nutrition mission in India. This paper examined the linkages between utilization of ICDS and underweight among children aged 6-59 months. The study utilized data from two recent rounds of the National Family Health Survey (NFHS-4 [2015-2016] and NFHS-5 [2019-2021]). Descriptive analyses were used to assess the change in utilization of ICDS and the prevalence of underweight at the national and state levels. Multivariable logistic regressions were performed to examine factors associated with the utilization of ICDS and underweight. Linkages between utilization of ICDS and underweight were examined using the difference-in-differences (DID) approach. Utilization of ICDS increased from 58% in 2015-2016to 71% in 2019-2021. The prevalence of underweight decreased from 37% to 32% in the same period. Changes in ICDS utilization and underweight prevalence varied considerably across states, socioeconomic and demographic characteristics. Results from decomposition of DID models suggest that improvements in ICDS explained 9%-12% of the observed reduction in underweight children between 2016 and 2021, suggesting that ICDS made a modest but meaningful contribution in addressing undernutrition among children aged 6-59 months in this period.

Young Child Undernutrition: Crucial to Prioritize Nutrition Interventions in the First 1000 Days of Life.

The implications of young childhood undernutrition on health, development and productivity are grave. In the last two decades, global and Indian studies on undernutrition in under five years have concluded that stunting and underweight rate increases steadily between 0-24 mo, and then stabilises. The available evidence highlights the significance of concentrating interventions to tackle child undernutrition in the first 1000 d of life, which should aim at universal coverage of essential nutrition interventions (ENIs) and maternal-child health care package comprising maternal nutrition care, adoption of appropriate infant and young child feeding practices (IYCF), iron-folic acid supplementation, immunization, deworming, appropriate management of childhood illness etc. Additionally, it is critical to address context specific nutrition sensitive measures such as socio-economic empowerment of women, preventing domestic violence, adolescent conception, appropriate water -sanitation-hygiene and family planning services etc. Mapping of the 'at risk' households having a member falling in the 1000 d window needs special attention and is central to the ongoing efforts in India through the National Nutrition Mission/ POSHAN Abhiyaan. However, for effective implementation, there is an urgent need to consider to shift the lead responsibility of ENIs in the first 1000 d of life to the health care system in India and strategize to integrate maternal nutrition care interventions and establishing of IYCF practices by ensuring optimum use of contacts with antenatal care and routine child immunization services.

The Outbreaks of Acute Encephalitis Syndrome in Uttar Pradesh, India (1978-2020) and Its Effective Management: A Remarkable Public Health Success Story.

IntroductionAcute encephalitis syndrome (AES) is a major public health enigma in India and the world. Uttar Pradesh (UP) is witnessing recurrent and extensive seasonal AES outbreaks since 1978. Government of India and UP state government have devised various mitigation measures to reduce AES burden and AES associated mortality, morbidity and disability in Uttar Pradesh. The aim of this study was to describe the public health measures taken in order to control seasonal outbreaks of AES in UP between 1978 and 2020.MethodsWe used literature review as a method of analysis, including the Indian government policy documents. This review utilized search engines such as PubMed, Google Scholar, Research Gate, Cochrane, Medline to retrieve articles and information using strategic keywords related to Acute Encephalitis Syndrome. Data was also collected from progress reports of government schemes and websites of Indian Council of Medical Research (ICMR), National Vector Borne Disease Control Programme (NVBDCP) and Integrated Disease Surveillance Programmes (IDSP).ResultsThe incidence of AES cases in UP have declined from 18.2 per million population during 2005-2009 to 15 per million population during 2015-2019 [CI 12.6–20.6, P-value < 0.001] and case fatality rate (CFR) reduced from 33% during 1980-1984 to 12.6% during 2015-2019 [CI 17.4–30.98, P-value < 0.001]. AES incidence was 9 (2019) and 7 (2020) cases per million populations respectively and CFR was 5.8% (2019) and 5% (2020). This decline was likely due to active surveillance programs identifying aetiological agents and risk factors of AES cases. The identified etiologies of AES include Japanese encephalitis virus (5–20%), Enterovirus (0.1–33%), Orientia tsutsugamushi (45–60%) and other viral (0.2–4.2%), bacterial (0–5%) and Rickettsial (0.5–2%) causes. The aggressive immunization programs against Japanese encephalitis with vaccination coverage of 72.3% in UP helped in declining of JE cases in the region. The presumptive treatment of febrile cases with empirical Doxycycline and Azithromycin (EDA) caused decline in Scrub Typhus-AES cases. Decrease in incidence of vector borne diseases (Malaria, Dengue, Japanese Encephalitis and Kala Azar) i.e., 39.6/100,000 population in 2010 to 18/100,000 population in 2017 is highlighting the impact of vector control interventions. Strengthening healthcare infrastructure in BRD medical college and establishment of Encephalitis Treatment Centre (ETC) at peripheral health centres and emergency ambulance services (Dial 108) reduced the referral time and helped in early treatment and management of AES cases. The AES admissions increased at ETC centres to 60% and overall case fatality rate of AES declined to 3%. Under clean India mission and Jal Jeevan mission, proportion of population with clean drinking water increased from 74.3% in 1992 to 98.7% in 2020. The proportion of household having toilet facilities increased from 22.9% in 1992 to 67.4% in 2020. Provisions for better nutritional status under state and national nutrition mission helped in reducing the burden of stunting (52%) and wasting (53.4%) among under five children in 1992 to 38.8% (stunting) and 36.8% (wasting) in year 2018. These factors have all likely contributed to steady AES decline observed in UP.ConclusionThere is a recent steady decline in AES incidence and CFR since implementation of intensive AES surveillance system and JE immunization campaigns which is highlighting the success of interventions made by central and state government to control seasonal AES outbreaks in UP. Currently, AES incidence is 9 cases per million population (in year 2019) and mortality is 5.8%.

Screening and management options for severe thinness during pregnancy in India.

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.

TRENDS OF MALNUTRITION AND UNDER-FIVE MORTALITY AMONG CHILDREN IN INDIA - TROTTING `PUBLIC HEALTH CHALLENGES AMIDST EFFECTIVE STRATEGIES: A REVIEW.

OBJECTIVE: Malnutrition is a complex multitude issue. Global estimates found that malnutrition alone is responsible for the forty five percent of deaths among children under-five years of age which is otherwise preventable. India has started its war against malnutrition way back in 1970. The aim is to analyse: the trends on malnutrition indicators; statewise prevalence of malnutrition among under-five children; the under-five mortality rate in India; the socio-economicdemographic factors common to both malnutrition and U5MR and national nutritional policy in system and its challenges ahead. MATERIALS AND METHODS: Desk review and analysis National Family Health Survey1 to 5 and Combined national nutritional surveys, Sample registration survey – recent and review of the relevant journal articles and editorials. RESULTS: India is one of the worst affected countries of the World and is under 'Very High Category' for all the three major indicators of malnutrition: Stunting, wasting and under nutrition. Integrated Child Development Services, which developed as an experimental initiative in India, has evolved overtime imbibing Millennium development goals, Global nutritional policy, Sustainable development goals to address the overall complexity of malnutrition including immunization, maternal health, adolescent health, primary health care, best feeding practices, sanitation and hygiene practices. Yet, India ranks One hundredth and two rank out of one hundred seventeen countries as per the Global Hunger Index report, 2019. CONCLUSION: A more concerted and intersectoral collaborative actions, a real time monitoring, independent reviewing and progressive efforts would only help India's National nutrition mission to achieve its goal 'Kuposhan Mukt Bharat', malnutrition free India by 2025.

Optimizing the impact of health and related programmes / policies to address the issue of Childhood Obesity in India----A narrative review.

Non-communicable diseases are already acknowledged as a double burden, and now childhood obesity is putting extra strain on our health system. The current paper aimed to analyze the ongoing health and related programmes/policies in India, and we discussed the existing opportunities in the programmes to address the issue of childhood obesity in India. We searched the “MEDLINE,” “PsycINFO,” “Scopus,” “Web of Science,” and “Google Scholar” databases using the following keywords: (“overweight”) and (“obesity”), (“childhood obesity”), (“nutritional programmes in India”), (“Health policies in India”), (“malnourished children in India”) in combination with each other and in truncated form. All the relevant articles and policy documents (MOHFW, INDIA) available in the public domain were included to support the argument for this narrative review. We found that we have programme gaps like guidelines issues by Food Safety Standards Authority of India to tackle childhood obesity and it has not been strictly implemented due to multiple reasons. School health programme has an opportunity to address the issue of childhood obesity, but at the ground level the outcomes are not very promising. The National Nutrition Mission have only focussed on undernutrition and anemia problem, ignoring the overweight/childhood obesity. Primary care physicians are key players in the treatment of childhood obesity, yet rates of obesity management in the primary care setting are low. National Programme for prevention & Control of Cancer, Diabetes, Cardiovascular Diseases & stroke is dealing with health promotion and prevention, early diagnosis, and management of all ages, except children. Diet provided in Integrated Child Development Scheme is calculated based on calories, not by the quality which is a concern to us. The breastfeeding promotion programme named Mothers Absolute Affection programme has not been implemented with letter and spirit. Other than health programmes, we assume that Ministry of Urban Planning, Foreign Direct Investment policy, Advertisement Council of India and many more sector/policy/programme are indirectly responsible for the increasing burden of childhood obesity in India. Lack of awareness and wrong perception also responsible for the development of childhood obesity. We have multiple National Health Programmes and Policies to address the childhood malnutrition, but are focussing the undernutrition component only, ignoring overnutrition problem in the children, which is emerging as quadruple burden to our health system. Appropriate actions and inclusion of suggestions provided in this study for the improvement of the programmes at the practical level needs to be considered by the policy makers to halt the ever-rising trend of childhood obesity and primary care physicians should play a leadership role.

National Nutrition Mission (Poshan Abhiyaan) to Eradicate Obesity in India: Way Forward

National Nutrition Mission (Poshan Abhiyaan) to Eradicate Obesity in India: Way Forward

Implementing a “convergent” framework of action against childhood malnutrition in urban informal settlements of Mumbai: Frontline perspectives

Context:The National Nutrition Mission (POSHAN Abhiyaan) intends to “converge” nutrition-related program components across sectors (nutrition, health, water, and sanitation). In this study, we have examined the perspectives of Anganwadi workers (AWWs), the frontline workers of the Integrated Child Development Services, on working in convergence with the public health sector.Methods:This exploratory qualitative study was done between June 2018 and June 2019 in two urban informal settlements in Mumbai. We conducted in-depth interviews with 26 AWWs and their supervisors, purposively sampled and diversified in terms of age, education, and years of experience. We used the software NVivo version 12 to aid analysis.Results:Most AWWs acknowledged that a convergent framework of action between “nutrition” and “health” was likely to be beneficial to the community. However, they also shared that cross-sector convergence was currently limited due to technical unfamiliarity with “health-sector” issues in the frontline, discomfort with data sharing, and lack of meaningful incentives for joint work. Broader organizational challenges such as poor infrastructure and lack of supervision, as well as challenges in the urban context (migration and cultural barriers) further hindered joint activities.Conclusions:The findings indicate that critical structural gaps in the urban setup of ICDS need to be addressed and AWWs need to be better familiarized with the changing roles expected from them under POSHAN Abhiyaan. To work better with the health sector, the work timings of AWWs need to be aligned with those of the health sector and meaningful financial incentives need to be put in place for cross-sector activities.

Supporting efforts to address malnutrition in the context of the COVID-19 pandemic in India: An emergency need

India has been on a steady march to address malnutrition in the last decade. The nutrition community has worked on building consensus on key actions, implementation platforms were put in place and financing for nutrition slowly increased. Under the strong leadership of the Prime Minister, a revolutionary program to address malnutrition was launched in 2018. As actions under the mission accelerated, the COVID-19 pandemic arrived in early 2020. Affecting health systems, food systems, nutrition programs, social safety nets, and the economy, the pandemic has the potential to exacerbate the challenge of malnutrition in multiple ways. India can mitigate some of the possible ways in which COVID-19 will affect malnutrition but will require strong leadership and continued commitment, adaptation of the national nutrition mission, strengthening of the social safety net and innovative evidence-based data to take informed decisions, implement them and ensure feedback to take necessary corrective action. In this article, we outline some challenges and key areas for action. We conclude that India's nutrition journey is too important to be derailed by a crisis like COVID-19. This is a clarion call for the nutrition community in India to rally strongly to support continued attention to malnutrition in all its forms, to generate relevant evidence, and to support and engage all of society to urgently and adequately address malnutrition in the context of the COVID-19 pandemic. We have come too far to turn back now.

A cross sectional study of nutritional status among first semester adolescents of a polytechnic college in North Karnataka, India

Introduction: Adolescence is a period of rapid growth & maturity, both physiologically & psychologically. Adult weight of 35% & 11-18% of adult height is acquired during adolescent age. Nutrition has a key role to support this rapid growth and development. Objective of the study: To assess nutritional status among first semester adolescents of a Polytechnic College in North Karnataka. Methodology: All the new admissions of a polytechnic college in North Karnataka for the year 2015 were included in the study after Ethical Clearance and permission from the Principal of the college. Age of each student was determined by date of birth. Weight was recorded by a portable weighing machine without footwear. The standing height was recorded by asking the student to stand against the wall, heels together without shoes. The height was measured with the help of a flexible measuring tape graduated in centimeters and inches. Body mass index was calculated using the formula weight in kilogram/Height in metre.2 Each student classified according to WHO BMI for age and Height for age. Data was analyzed using percentages and Fischer exact test. Results: Out of 307 admissions of 2015, 214 (69.71%) were boys and 93 (30.29%) were girls. Majority (69.71%) were between 17 - 19 years and 25.08% were between 15 - 16 years. Students > 20 years were 5.21%. Out of 291 adolescent students between 15 - 19 years, thinness was observed in 24.74% and severe thinness in 19.59%. Regarding height for age, stunting was observed in 18.90% and severe stunting in 2.06%. Conclusion: National nutrition mission could be the only answer to solve thinness and stunting in adolescents. Keywords: Stunting, Thinness, Adolescents.

Assessing inequalities and regional disparities in child nutrition outcomes in India using MANUSH \u2013 a more sensitive yardstick

BackgroundIndia is strongly committed to reducing the burden of child malnutrition, which has remained a persistent concern. Findings from recent surveys indicate co-existence of child undernutrition, micronutrient deficiency and overweight/obesity, i.e. the triple burden of malnutrition among children below 5 years. While considerable efforts are being made to address this challenge, and several composite indices are being explored to inform policy actions, the methodology used for creating such indices, i.e., linear averaging, has its limitations. Briefly put, it could mask the uneven improvement across different indicators by discounting the ‘lagging’ indicators, and hence not incentivising a balanced improvement. Signifying negative implications on policy discourse for improved nutrition. To address this gap, we attempt to develop a composite index for estimating the triple burden of malnutrition in India, using a more sensitive measure, MANUSH.MethodologyData from publicly available nation-wide surveys - National Family Health Survey (NFHS) and Comprehensive National Nutrition Survey (CNNS), was used for this study. First, we addressed the robustness of MANUSH method of composite indexing over conventional aggregation methods. Second, using MANUSH scores, we assessed the triple burden of malnutrition at the subnational level over different periods NHFS- 3(2005–06), NFHS-4 (2015–16) and CNNS (2106–18). Using mapping and spatial analysis tools, we assessed neighbourhood dependency and formation of clusters, within and across states.ResultMANUSH method scores over other aggregation measures that use linear aggregation or geometric mean. It does so by fulfilling additional conditions of Shortfall and Hiatus Sensitivity, implicitly penalising cases where the improvement in worst-off dimension is lesser than the improvement in best-off dimension, or where, even with an overall improvement in the composite index, the gap between different dimensions does not reduce. MANUSH scores helped in revealing the gaps in the improvement of nutrition outcomes among different indicators and, the rising inequalities within and across states and districts in India. Significant clusters (p < 0.05) of high burden and low burden districts were found, revealing geographical heterogeneities and sharp regional disparities. A MANUSH based index is useful in context-specific planning and prioritising different interventions, an approach advocated by the newly launched National Nutrition Mission in India.ConclusionMANUSH based index emphasises balanced development in nutritional outcomes and is hence relevant for diverse and unevenly developing economy like India.

A Healthier India: Making the POSHAN Abhiyaan a Jan Andolan

India’s growing identification as a super economic power is in stark contrast to her severe levels of malnutrition. Although the government has introduced several schemes through the years to fight and control malnutrition, the schemes have failed to realise their objectives. The Government of India has now launched the National Nutrition Mission or POSHAN Abhiyaan---one of the most ambitious schemes till date. While the article critically analyses the gaps in the implementation of the earlier schemes, it provides an overview of the POSHAN Abhiyaan and argues that among the four pillars identified for its success, the Jan Andolan or mass movement is crucial for its success. The article further proposes a conceptual model for strengthening the Jan Andolan.

Mapping of variations in child stunting, wasting and underweight within the states of India: the Global Burden of Disease Study 2000–2017

BackgroundTo inform actions at the district level under the National Nutrition Mission (NNM), we assessed the prevalence trends of child growth failure (CGF) indicators for all districts in India and inequality between districts within the states. MethodsWe assessed the trends of CGF indicators (stunting, wasting and underweight) from 2000 to 2017 across the districts of India, aggregated from 5 × 5 km grid estimates, using all accessible data from various surveys with subnational geographical information. The states were categorised into three groups using their Socio-demographic Index (SDI) levels calculated as part of the Global Burden of Disease Study based on per capita income, mean education and fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using coefficient of variation (CV). We projected the prevalence of CGF indicators for the districts up to 2030 based on the trends from 2000 to 2017 to compare with the NNM 2022 targets for stunting and underweight, and the WHO/UNICEF 2030 targets for stunting and wasting. We assessed Pearson correlation coefficient between two major national surveys for district-level estimates of CGF indicators in the states. FindingsThe prevalence of stunting ranged 3.8-fold from 16.4% (95% UI 15.2–17.8) to 62.8% (95% UI 61.5–64.0) among the 723 districts of India in 2017, wasting ranged 5.4-fold from 5.5% (95% UI 5.1–6.1) to 30.0% (95% UI 28.2–31.8), and underweight ranged 4.6-fold from 11.0% (95% UI 10.5–11.9) to 51.0% (95% UI 49.9–52.1). 36.1% of the districts in India had stunting prevalence 40% or more, with 67.0% districts in the low SDI states group and only 1.1% districts in the high SDI states with this level of stunting. The prevalence of stunting declined significantly from 2010 to 2017 in 98.5% of the districts with a maximum decline of 41.2% (95% UI 40.3–42.5), wasting in 61.3% with a maximum decline of 44.0% (95% UI 42.3–46.7), and underweight in 95.0% with a maximum decline of 53.9% (95% UI 52.8–55.4). The CV varied 7.4-fold for stunting, 12.2-fold for wasting, and 8.6-fold for underweight between the states in 2017; the CV increased for stunting in 28 out of 31 states, for wasting in 16 states, and for underweight in 20 states from 2000 to 2017. In order to reach the NNM 2022 targets for stunting and underweight individually, 82.6% and 98.5% of the districts in India would need a rate of improvement higher than they had up to 2017, respectively. To achieve the WHO/UNICEF 2030 target for wasting, all districts in India would need a rate of improvement higher than they had up to 2017. The correlation between the two national surveys for district-level estimates was poor, with Pearson correlation coefficient of 0.7 only in Odisha and four small north-eastern states out of the 27 states covered by these surveys. InterpretationCGF indicators have improved in India, but there are substantial variations between the districts in their magnitude and rate of decline, and the inequality between districts has increased in a large proportion of the states. The poor correlation between the national surveys for CGF estimates highlights the need to standardise collection of anthropometric data in India. The district-level trends in this report provide a useful reference for targeting the efforts under NNM to reduce CGF across India and meet the Indian and global targets.

The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017

SummaryBackgroundMalnutrition is a major contributor to disease burden in India. To inform subnational action, we aimed to assess the disease burden due to malnutrition and the trends in its indicators in every state of India in relation to Indian and global nutrition targets.MethodsWe analysed the disease burden attributable to child and maternal malnutrition, and the trends in the malnutrition indicators from 1990 to 2017 in every state of India using all accessible data from multiple sources, as part of Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three groups using their Socio-demographic Index (SDI) calculated by GBD on the basis of per capita income, mean education, and fertility rate in women younger than 25 years. We projected the prevalence of malnutrition indicators for the states of India up to 2030 on the basis of the 1990–2017 trends for comparison with India National Nutrition Mission (NNM) 2022 and WHO and UNICEF 2030 targets.FindingsMalnutrition was the predominant risk factor for death in children younger than 5 years of age in every state of India in 2017, accounting for 68·2% (95% UI 65·8–70·7) of the total under-5 deaths, and the leading risk factor for health loss for all ages, responsible for 17·3% (16·3–18·2) of the total disability-adjusted life years (DALYs). The malnutrition DALY rate was much higher in the low SDI than in the middle SDI and high SDI state groups. This rate varied 6·8 times between the states in 2017, and was highest in the states of Uttar Pradesh, Bihar, Assam, and Rajasthan. The prevalence of low birthweight in India in 2017 was 21·4% (20·8–21·9), child stunting 39·3% (38·7–40·1), child wasting 15·7% (15·6–15·9), child underweight 32·7% (32·3–33·1), anaemia in children 59·7% (56·2–63·8), anaemia in women 15–49 years of age 54·4% (53·7–55·2), exclusive breastfeeding 53·3% (51·5–54·9), and child overweight 11·5% (8·5–14·9). If the trends estimated up to 2017 for the indicators in the NNM 2022 continue in India, there would be 8·9% excess prevalence for low birthweight, 9·6% for stunting, 4·8% for underweight, 11·7% for anaemia in children, and 13·8% for anaemia in women relative to the 2022 targets. For the additional indicators in the WHO and UNICEF 2030 targets, the trends up to 2017 would lead to 10·4% excess prevalence for wasting, 14·5% excess prevalence for overweight, and 10·7% less exclusive breastfeeding in 2030. The prevalence of malnutrition indicators, their rates of improvement, and the gaps between projected prevalence and targets vary substantially between the states.InterpretationMalnutrition continues to be the leading risk factor for disease burden in India. It is encouraging that India has set ambitious targets to reduce malnutrition through NNM. The trends up to 2017 indicate that substantially higher rates of improvement will be needed for all malnutrition indicators in most states to achieve the Indian 2022 and the global 2030 targets. The state-specific findings in this report indicate the effort needed in each state, which will be useful in tracking and motivating further progress. Similar subnational analyses might be useful for other low-income and middle-income countries.FundingBill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Estimating the burden of child malnutrition across parliamentary constituencies in India: A methodological comparison.

In India, data on key developmental indicators used to formulate policies and interventions are routinely available for the administrative unit of districts but not for the political unit of parliamentary constituencies (PC). Recently, Swaminathan et al. proposed two methodologies to generate PC estimates using randomly displaced GPS locations of the sampling clusters (‘direct’) and by building a crosswalk between districts and PCs using boundary shapefiles (‘indirect’). We advance these methodologies by using precision-weighted estimations based on hierarchical logistic regression modeling to account for the complex survey design and sampling variability. We exemplify this application using the latest National Family Health Survey (NFHS, 2016) to generate PC-level estimates for two important indicators of child malnutrition – stunting and low birth weight – that are being monitored by the Government of India for the National Nutrition Mission targets. Overall, we found a substantial variation in child malnutrition across 543 PCs. The different methodologies yielded highly consistent estimates with correlation ranging r = 0.92-0.99 for stunting and r = 0.81-0.98 for low birth weight. For analyses involving data with comparable nature to the NFHS (i.e., complex data structure and possibility to identify a potential PC membership), modeling for precision-weighted estimates and direct methodology are preferable. Further field work and data collection at the PC level are necessary to accurately validate our estimates. An ideal solution to overcome this gap in data for PCs would be to make PC identifiers available in routinely collected surveys and the Census.

Editorial.

Editorial.

Household food insecurity and children's dietary diversity and nutrition in India. Evidence from the comprehensive nutrition survey in Maharashtra.

We analyse data from the 2012 Comprehensive Nutrition Survey in the State of Maharashtra, India, which surveyed 2,630 households. This is a unique dataset because in addition to nutritional status of mothers and children, it has information on diets of women and children and household food security. This rich dataset allows us to address three issues: whether household food security predicts higher diet diversity in children aged 6-23months; whether household food security predicts lower risk of undernutrition; and whether the lower risk of undernutrition in children who live in food secure households is mediated by improved diet diversity for children. We find that children from moderately food insecure and severely food insecure households are more likely to have lower diet diversity scores. We find that the odds of a child being severely stunted, severely underweight, or severely wasted are higher in severely food insecure households. After controlling for children's diet diversity, and other child, maternal and household characteristics, we find that household food security is no longer statistically associated with stunting, wasting, or underweight. However, diet diversity of children is statistically significantly associated with whether a child is stunted or underweight. Our results although not causal provide evidence for understanding the extent to which household food insecurity affects children's diet diversity and how both these factors affect nutrition outcomes in children. Our analysis informs Government of Maharashtra's and India's National Nutrition Mission in their efforts for formulating appropriate policies and programmes to address child undernutrition.

Under-Nutrition in India – A Forgotten National Nutrition Policy without a National Programme

This Paper analyses why and for how long high levels of malnutrition have afflicted India’s population. It does a historical analysis of how two centuries of colonial rule created the enabling environment for perpetuation of chronic malnutrition through interplay of increasing poverty, decreasing literacy, de-industrialization, an increased agricultural labour force, low wages, deteriorating health and nutritional status. The paper discusses the James Bhore Committee Report, 1946, first Health and Nutrition Survey in India, and the alarming nutrition data it reveals. It examines independent India’s responses- Article 47 of the Constitution, the beginnings of nutrition governance in India, development of nutrition strategies and interventions in the Five Year Plans, the announcement of the Minimum Needs Programme in 1974, launch of the ICDS in 1975, and adoption of the National Nutrition Policy (NNP) in 1993, and evaluates their impact. The paper concludes that the problem of under-nutrition in India could decrease faster if its structural causes are programmatically addressed, namely, protein-calorie-micronutrient deficit in about 50% of the people’s diet; its inter-generational character; the information and awareness deficit in the community about proper nutritional care of infants, children, adolescent girls, and pregnant women. Important prescriptions of the National Nutrition Policy, 1993, were never implemented, and India has no national programme to eradicate malnutrition. The paper concludes with recommendations that the Niti Aayog take charge of this multi-sectoral subject, and constitute a High Power Committee to revise the NNP and draft the National Nutrition Mission within a given time frame.