Geo-visualising Diet, Anthroprometric and Clinical Indicators for Children in India

Dietary diversity (DD) measures dietary variation in children. Factors
at the child, community, and state levels may be associated with poor
child nutritional outcomes. However, few studies have examined the role
of macro-level factors on child DD. This study seeks to 1) describe the
distribution of child DD in India, 2) examine the variation in DD attributable
to the child, community and state levels, and 3) explore the relationship
between community socioeconomic context and child DD. Using nationally
representative data from children aged 6-23 months in India, multilevel
models were used to determine the associations between child DD and
individual- and community-level factors. There was substantial variation in
child DD score across demographic and socioeconomic characteristics. In an
age and sex-only adjusted regression model, the largest portion of variation
in child DD was attributable to the child level (75%) while the portions of
variance attributable to the community-level and state level were similar to
each other (15% and 11%). Including individual-level socioeconomic factors
explained 35.6 percent of the total variation attributed to child DD at the
community level and 24.8 percent of the total variation attributed to child
DD at the state level. Finally, measures of community disadvantage were
associated with child DD in when added to the fully adjusted model. This
study suggests that both individual and contextual factors are associated with
child DD. These results suggest that a population-based approach combined
with a targeted intervention for at-risk children may be needed to improve
child DD in India.

As per the latest National Nutrition Monitoring Bureau, which has been collecting data on diet and nutritional status of rural, tribal and urban populations for almost four decades, the calorie intake of children (1-3 years) in rural areas was only about 70% of their requirement due to shortage.

Since the publication of our study, the Government of India has released
preliminary estimates from the on-going latest round of National Family
Health Surveys (2015–2016) on the prevalence of stunting, underweight
and wasting for a limited number of states in India (International Institute
for Population Sciences, 2016). We compared the prevalence from the most
recent data for 13 states to the corresponding states from 2005–06 (Fig. 3).
Declines in undernutrition between 2005–06 and 2015–16 averaged 1.3%/
year for stunting, 1.6%/year for underweight and 0.4%/year for wasting since
2015 (International Institute for Population Sciences, 2016). The sluggish
pace of decline suggests that undernutrition continues to be a major disease
burden among Indian children. It also suggests that macroeconomic growth
experienced by India in recent years has not contributed to any meaningful
reductions in child undernutrition in India (Subramanian et al., 2016,
Subramanian and Subramanyam, 2015, Subramanyam et al., 2011). As we
observed in our original study (Corsi et al., 2015), and elsewhere (Subramanian
et al., 2016), there is an urgent need to consider direct investments in
conditions that more generally are reflective of the upstream and structural
determinants of undernutrition. Specifically, policies and interventions that
aim to provide and sustain nutritional security at the household level are
critical to eliminating child undernutrition in India. Pursuing interventions in
proximal risk factors without any improvements to broader socioeconomic
and structural conditions, to put it bluntly, is likely to be waste of time and
resources with little impact on reducing the burden of undernutrition among
children in India.

Stunting and chronic undernutrition among children in South Asia remain
a major unresolved global health issue. There are compelling intrinsic and
moral reasons to ensure that children attain their optimal growth potential
facilitated via promotion of healthy living conditions. Investments in efforts to
ensure that children’s growth is not faltered also have substantial instrumental
benefits in terms of cognitive and economic development. Using the case of
India, we critique three prevailing approaches to reducing undernutrition
among children: an over-reliance on macroeconomic growth as a potent
policy instrument, a disproportionate focus on interpreting undernutrition as
a demand-side problem and an over-reliance on unintegrated single-factorial
(one at a time) approaches to a policy and research. Using existing evidence, we
develop a case for support-led policy approach with a focus on integrated and
structural factors to addressing the problem of undernutrition among children
in India.

Empirical evidence suggests that macroeconomic growth in India is not
correlated with any substantial reductions in the prevalence of child undernutrition over time. This study investigates the two commonly hypothesized pathways through which macroeconomic growth is expected to reduce child undernutrition: (1) an increase in public developmental expenditure and (2) a reduction in aggregate income-poverty levels. For the anthropometric data on children, we draw on the data from two crosssectional waves of National Family Health Survey conducted in 1992-1993 and 2005-2006, while the data for per capita net state domestic product and per capita public spending on developmental expenditure and headcount ratio of poverty were obtained from the Reserve Bank of India and the Government of India expert committee reports. We find that between 1992-1993 and 2005-2006, state-level macroeconomic growth was not associated with any substantial increases in public development expenditure or substantial reductions in poverty at the aggregate level. Furthermore, the association between changes in public development expenditure or aggregate poverty and changes in undernutrition was small. In summary, it appears that the inability of macroeconomic growth to translate into reductions in child undernutrition in India is likely a consequence of the macroeconomic growth not translating into substantial investments in development expenditure that could matter for children’s nutritional status and neither did it substantially improve incomes of the poor, a group where undernutrition is also the highest. The findings here build a case to advocate a ‘support-led’ strategy for reducing undernutrition rather than simply relying on a ‘growth-mediated’ strategy. Key messages Increases in macroeconomic growth have not been accompanied by substantial increases in public developmental spending or reduction in aggregate poverty headcount ratio in India. Association between increases in public development expenditure or poverty headcount ratios and changes in child undernutrition, in particular, child stunting, is small to null. Reducing the burden of undernutrition in India cannot be accomplished solely relying on a growth-mediated strategy, and a concerted support-led strategy is required.

About two of every five undernourished young children of the world live
in India. These high levels of child undernutrition have persisted in India for
several years, even in its relatively well-developed states. Moreover, this
pattern was observed during a period of rapid economic growth. Evidence
from India and other developing countries suggests that economic growth has
little to no impact on reducing child undernutrition. We argue that a growthmediated
strategy is unlikely to be effective in tackling child undernutrition
unless growth is pro-poor and leads to investment in programs addressing the
root causes of this persistent challenge.

Recently, Prime Minister Manmohan Singh released a survey on child under-nutrition in rural India in 2010-11 (Hunger and Malnutrition Survey,HUNGaMA). Sadly,the new data reinforced the existence of an India marked by substantially low levels of something absolutely vital for adequate human development. The survey found that 42 per cent of the under-five children were underweight and 59 per cent were stunted in the 100 focus districts. Remarkably,in six districts with the best child development index,the prevalence of underweight (33 per cent) and stunting (43 per cent) among children,while somewhat lower,was still substantially high — suggesting the endemic and persistent nature of the under-nutrition burden. Even though child under-nutrition remains very high,do the data from HUNGaMA suggest an improvement over previous assessments? Data from the district-level health survey (DLHS) of 2002-2004 provide some answers. The DLHS includes data on underweight among children under six from hundreds of districts across India. In the 100 focus districts,the prevalence of underweight appeared to have reduced 11 percentage points from 53 per cent in the DLHS to 42 per cent in the HUNGaMA Survey. A similar comparison of changes in the prevalence of stunting is not possible since DLHS did not measure the height of children. Other aspects of the results from the HUNGaMA survey reiterate older patterns. For instance,under-nutrition is inversely associated with socio-economic status; thus children from low income households or whose mother had low levels of education have higher prevalence of under-nutrition.

Leg length has been suggested as a proxy for nutritional and environmental
exposures in childhood given the associations observed in some Western
populations. Sanjay Kinra et al. present a careful assessment of this
hypothesis in an Indian population in this issue of the International Journal of
Epidemiology and observe no association between nutritional supplementation and relative leg length, and relative lower leg length, among adolescents in the Hyderabad cohort. Although intriguing, given previous findings and the proposed sensitivity of ‘lower’ leg length as a marker for nutritional status, the null finding reported by Kinra and colleagues is in accord with other studies in non-Western populations. A number of alternative anthropometric, body compositional and biochemical methods are available for ascertaining nutritional status in children. Depending on the setting and the objective (individual clinical impression vs population nutritional assessment), these methods may have important advantages and disadvantages that we briefly consider.

Economic growth is widely perceived as a major policy instrument in reducing
childhood undernutrition in India. We assessed the association between
changes in state per capita income and the risk of undernutrition among
children in India. Data for this analysis came from three cross-sectional waves
of the National Family Health Survey (NFHS) conducted in 1992–93, 1998–
99, and 2005–06 in India. The sample sizes in the three waves were 33,816,
30,383, and 28,876 children, respectively. After excluding observations
missing on the child anthropometric measures and the independent variables
included in the study, the analytic sample size was 28,066, 26,121, and 23,139,
respectively, with a pooled sample size of 77,326 children. The proportion
of missing data was 12%–20%. The outcomes were underweight, stunting,
and wasting, defined as more than two standard deviations below the World
Health Organization–determined median scores by age and gender. We also
examined severe underweight, severe stunting, and severe wasting. The main
exposure of interest was per capita income at the state level at each survey
period measured as per capita net state domestic product measured in 2008
prices. We estimated fixed and random effects logistic models that accounted
for the clustering of the data. In models that did not account for survey-period
effects, there appeared to be an inverse association between state economic
growth and risk of undernutrition among children. However, in models
accounting for data structure related to repeated cross-sectional design
through survey period effects, state economic growth was not associated
with the risk of underweight (OR 1.01, 95% CI 0.98, 1.04), stunting (OR 1.02,
95% CI 0.99, 1.05), and wasting (OR 0.99, 95% CI 0.96, 1.02). Adjustment for
demographic and socioeconomic covariates did not alter these estimates.
Similar patterns were observed for severe undernutrition outcomes. We
failed to find consistent evidence that economic growth leads to reduction
in childhood undernutrition in India. Direct investments in appropriate health
interventions may be necessary to reduce childhood undernutrition in India.

India experienced a rapid economic boom between 1991 and 2007. However,
this economic growth has not translated into improved nutritional status
among young Indian children. Additionally, no study has assessed the trends
in social disparities in childhood undernutrition in the Indian context. We
examined the trends in social disparities in underweight and stunting among
Indian children aged less than three years using nationally representative
data. We analyzed data from the three cross-sectional rounds of National
Family Health Survey of India from 1992, 1998 and 2005. The social factors
of interest were: household wealth, maternal education, caste, and urban
residence. Using multilevel modeling to account for the nested structure and
clustering of data, we fit multivariable logistic regression models to quantify
the association between the social factors and the binary outcome variables.
The final models additionally included age, gender, birth order of child,
religion, and age of mother. We analyzed the trend by testing for interaction
of the social factor and survey year in a dataset pooled from all three surveys.
While the overall prevalence rates of undernutrition among Indian children
less than three decreased over the 1992-2005 period, social disparities in
undernutrition over these 14 years either widened or stayed the same. The
absolute rates of undernutrition decreased for everyone regardless of their
social status. The disparities by household wealth were greater than the
disparities by maternal education. There were no disparities in undernutrition
by caste, gender or rural residence. There was a steady decrease in the
rates of stunting in the 1992-2005 period, while the decline in underweight
was greater between 1992 and 1998 than between 1998 and 2005. Social
disparities in childhood undernutrition in India either widened or stayed
the same during a time of major economic growth. While the advantages
of economic growth might be reaching everyone, children from better-off
households, with better educated mothers appear to have benefited to a
greater extent than less privileged children. The high rates of undernutrition
(even among the socially advantaged groups) and the persistent social
disparities need to be addressed in an urgent and comprehensive manner.

Prior research on the determinants of child health has focused on
contemporaneous risk factors such as maternal behaviors, dietary factors,
and immediate environmental conditions. Research on intergenerational
factors that might also predispose a child to increased health adversity
remains limited. To examine the association between maternal height and
child mortality, anthropometric failure, and anemia. We retrieved data from
the 2005-2006 National Family Health Survey in India (released in 2008).
The study population constitutes a nationally representative cross-sectional
sample of singleton children aged 0 to 59 months and born after January
2000 or January 2001 (n = 50 750) to mothers aged 15 to 49 years from all
29 states of India. Information on children was obtained by a face-to-face
interview with mothers, with a response rate of 94.5%. Height was measured
with an adjustable measuring board calibrated in millimeters. Demographic
and socioeconomic variables were considered as covariates. Modified Poisson
regression models that account for multistage survey design and sampling
weights were estimated. Mortality was the primary end point; underweight,
stunting, wasting, and anemia were included as secondary outcomes. In
adjusted models, a 1-cm increase in maternal height was associated with
a decreased risk of child mortality (relative risk [RR], 0.978; 95% confidence
interval [CI], 0.970-0.987; P < .001), underweight (RR, 0.971; 95% CI, 0.968-
0.974; P < .001), stunting (RR, 0.971; 95% CI, 0.968-0.0973; P < .001), wasting
(RR, 0.989; 95% CI, 0.984-0.994; P < .001), and anemia (RR, 0.998; 95% CI,
0.997-0.999; P = .02). Children born to mothers who were less than 145 cm
in height were 1.71 times more likely to die (95% CI, 1.37-2.13) (absolute
probability, 0.09; 95% CI, 0.07-0.12) compared with mothers who were at
least 160 cm in height (absolute probability, 0.05; 95% CI, 0.04-0.07). Similar
patterns were observed for anthropometric failure related to underweight
and stunting. Paternal height was not associated with child mortality or
anemia but was associated with child anthropometric failure. CONCLUSION:
In a nationally representative sample of households in India, maternal height
was inversely associated with child mortality and anthropometric failure.

Undernutrition continues to be a primary cause of ill-health and premature
mortality among children in developing countries. This paper examines how
the prevalence of undernutrition in children is measured and argues that
the standard indices of stunting, wasting and underweight may each be
underestimating the scale of the problem. This has important implications
for policy-makers, planners and organizations seeking to meet international
development targets. Using anthropometric data on 24 396 children in India,
we constructed an alternative composite index of anthropometric failure
(CIAF) and compared it with conventional indices. The CIAF examines the
relationship between distinct subgroups of anthropometric failure, poverty
and morbidity, showing that children with multiple anthropometric failures
are at a greater risk of morbidity and are more likely to come from poorer
households. While recognizing that stunting, wasting and underweight reflect
distinct biological processes of clear importance, the CIAF is the only measure
that provides a single, aggregated figure of the number of undernourished
children in a population.