Solutions to India's nutrition crisis may lie within states
Authors: Nandita Bhan
Journal: The Lancet Child & Adolescent Health (2019)

Strengthening of evidence to inform health policies is greatly needed in low-income and middle-income countries, such as India. In The Lancet Child and Adolescent Health, the India State-Level Disease Burden Initiative Malnutrition Collaborators1India State-Level Disease Burden Initiative Malnutrition CollaboratorsThe burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017.Lancet Child Adolesc Health. 2019; (published online Sep 17)https://doi.org/10.1016/S2352-4642(19)30273-1Google Scholar report the results of their study assessing the burden of child and maternal malnutrition and trends across Indian states, revealing the deep-rooted spread and nature of India's nutrition crisis. Rigorously triangulating data across national household surveys, dietary and nutrition surveys, and other epidemiological studies, estimating population attributable fractions and disability adjusted life years (DALYs) for malnutrition risk factors, assessing prevalences and changes between 1990 and 2017, and stratifying by state Socio-demographic Index, the study is an attempt to identify malnutrition hotspots in India. Four key highlights stand out that have implications for India's nutrition policies and for where investments in nutrition policies should be directed. First, despite several nutrition programmes targeted at women and children, nutrition indicators remain concerning. In 2017, 59·7% (95 CI 56·2–63·8) of children younger than 5 years were anaemic, 39·3% (38·7–40·1) were stunted, 32·7% (32·3–33·1) were underweight, and 21·4% (20·8–21·9) were born with low birthweight, and 54·4% (53·7–55·2) of women 15–49 years of age were anaemic.1India State-Level Disease Burden Initiative Malnutrition CollaboratorsThe burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017.Lancet Child Adolesc Health. 2019; (published online Sep 17)https://doi.org/10.1016/S2352-4642(19)30273-1Google Scholar In absolute terms, 68·2% (65·8–70·7) of the 1·04 million under-5 deaths in India in 2017 could be attributed to malnutrition, as could 67·1% (64·9–69·4) of DALYs. Furthermore, 25·4% of the global DALYs attributable to child and maternal malnutrition in 2017 occurred in India.1India State-Level Disease Burden Initiative Malnutrition CollaboratorsThe burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017.Lancet Child Adolesc Health. 2019; (published online Sep 17)https://doi.org/10.1016/S2352-4642(19)30273-1Google Scholar Second, state-level variation for key malnutrition indicators (total malnutrition for children younger than 5 years, low birthweight, stunting, underweight, and anaemia) exists across and within states. State differences for nutrition indicators were measured using the Socio-demographic Index (based on income, education, and fertility rate) that represented a macro income or development effect. State-level variation in malnutrition suggests that states need to develop and guide interventions for malnutrition in accordance with their unique circumstances within a broad framework, rather than within a single national approach. Third, from national and global standpoints, although India has made progress in reducing the burden of malnutrition between 1990 and 2017, as shown in this study, it is likely to fall short of achieving nutrition targets set by the National Nutrition Mission (NNM) for 20222Government of IndiaCabinet approves setting up of National Nutrition Mission. Press Information Bureau, 2017https://pib.gov.in/newsite/printrelease.aspx?relid=174025Date accessed: September 1, 2019Google Scholar and WHO and UNICEF for 2030.3WHOGlobal Targets 2025. To improve maternal, infant and young child nutrition. World Health Organization, Geneva2015https://www.who.int/nutrition/global-target-2025/en/Date accessed: September 1, 2019Google Scholar Gains and lags in progress vary by state and time and emphasise the need for continuous tracking of indicators and periodic assessments that use an iterative framework guided by ground assessments. Finally, although undernutrition poses a formidable challenge, the increase in overweight among children (nearly 12%) is concerning and risks taking attention away from the unfinished business of tackling undernutrition in India. India has implemented a range of nutrition programmes delivered through schools and community-based institutions (eg, Mid Day Meals and Integrated Child Development Services) that combine decades-old programme knowledge, along with population-focused approaches (eg, the national adolescent health strategy), and the National Nutrition Mission.4Government of IndiaNational Nutrition Mission. Poshan Abhiyaan. Ministry of Women and Child Development, 2017https://icds-wcd.nic.in/nnm/home.htmDate accessed: September 1, 2019Google Scholar Despite these programmes, data indicate that India will miss its nutrition targets. Reflection and investment in rigorous science on nutrition is, therefore, needed to understand why key malnutrition indicators that have lifelong consequences (such as stunting and anaemia) have remained highly prevalent and what fundamental factors continue to be unaddressed by current policy approaches. This study makes an important observation that the malnutrition burden differs by states, and more research into state-specific drivers is needed. Greater decentralisation, state-specific approaches that are informed by knowledge sharing by researchers and programme implementers, and state think-tanks could be a start.5Pahwa DH Beland D Federalism, decentralization, and health care policy reform in India.Public Admin Res. 2013; 2: 1Google Scholar, 6Kaur M Prinja S Singh PK Kumar R Decentralization of health services in India: barriers and facilitating factors.WHO South-East Asia J Public Health. 2012; 1: 94-104Crossref PubMed Google Scholar, 7Singh N Decentralization and public delivery of health care services in India.Health Affairs. 2008; 27: 991-1001Crossref Scopus (31) Google Scholar Reflection is also needed to understand what is working within states and why, with an understanding of the evidence on mechanisms and the theory of change, and to move away from a-theoretical evaluations. Although several programmes have reporting and evaluation mechanisms, they have often lacked good measures of malnutrition and their determinants that can provide meaningful insight into the lessons that can be learned. In this study,1India State-Level Disease Burden Initiative Malnutrition CollaboratorsThe burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017.Lancet Child Adolesc Health. 2019; (published online Sep 17)https://doi.org/10.1016/S2352-4642(19)30273-1Google Scholar the authors also suggested the use of an integrated life-course approach to improve nutrition outcomes rather than the current approach of reducing the burden of malnutrition through scattered programs. This life-course approach could ensure continuity of nutrition services for a woman or child at multiple points and consider health and social outcomes of nutrition services beyond programme-specified timespans (eg, early childhood or reproductive period) to avert later morbidity. However, this life-course approach will only be meaningful if it is embedded within a social equity framework that addresses the role of gender, caste, and poverty and their intersectionalities, which affect access and use of nutrition programmes.8Balarajan YS Fawzi WW Subramanian S Changing patterns of social inequalities in anaemia among women in India: cross-sectional study using nationally representative data.BMJ Open. 2013; 3e002233Crossref PubMed Scopus (46) Google Scholar Programmes that target women and children without considering intra-family dynamics (eg, gender inequities and women's agency) and broader social inequities (eg, caste discriminations) will be unable to address deep-rooted social factors that perpetuate nutritional inequalities in India.9Raj A Gender equity and universal health coverage in India.Lancet. 2011; 377: 618-619Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar Reflections on social inequities, especially disadvantage and discrimination, are not only needed within families and communities, but also within the health systems (eg, nutrition services) and their interaction with communities.10Newman C Time to address gender discrimination and inequality in the health workforce.Hum Resour Health. 2014; 12: 25Crossref PubMed Scopus (60) Google Scholar Data and evidence, such as those provided in this study, can provide a tool with which to initiate this reflection to seriously affect the ongoing nutritional crisis in India. I declare no competing interests. The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017Malnutrition 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. Full-Text PDF Open Access