Reducing childhood stunting in India: Insights from four subnational success cases

Global relevance of MGRS growth standards: the case of India

The most common measures of childhood undernutrition are based on anthropometric measures such as height-for-age (stunting/chronic undernutrition) and weight-for-height (wasting/acute undernutrition). It is well recognised that the determinants of undernutrition are multiple, including food intake, dietary diversity, health, sanitation and women's status. Currently, most countries across the world including India use the globally accepted WHO-Multicentre Growth Reference Study (MGRS) growth standards (2006) for the purposes of measurement as well as for evaluating progress on these metrics. However, there is some discussion on the universal relevance of these standards, and in the Indian context, whether these standards overestimate the prevalence of stunting, considering differences in genetic potential for growth. This is especially relevant in the context of increasing burden of obesity and non-communicable diseases in India. Based on a detailed review of literature, policy documents and expert inputs, this review paper discusses the relevance of the WHO growth standards for height/stunting, in the context of India. Issues discussed related to the MGRS methodology include pooling of data and intersite and intrasite variability, opting for standards as opposed to references, and external validity. Other issues related to plasticity of stunting and the influence of maternal heights are also discussed, in the context of analysing the appropriateness of using universal growth standards. Based on the review, it is recommended that the current standards may continue to be used until a newer global standard is established through a similar study.

Trends in the prevalence and social determinants of stunting in India, 2005-2021: findings from three rounds of the National Family Health Survey

Objectives

To assess social determinants of stunting and the shifts in contributions of socio-demographic factors to national prevalence trends in India between 2005 and 2021.

Methods

We leveraged data from three rounds of the National Family Health Survey (NFHS-3: 2005-2006, NFHS-4: 2015-2016, NFHS-5: 2019-2021) for 443 038 children under 5 years. Adjusted logistic regression models and a Kitigawa-Oaxaca-Blinder decomposition were deployed to examine how wealth, residence, belonging to a marginalised social group, maternal education and child sex contributed to changes in stunting prevalence.

Results

The decrease in stunting prevalence was notably slower between NFHS-4 and NFHS-5 (annual average rate of reduction (AARR): 1.33%) than between NFHS-3 and NFHS-4 (AARR: 2.20%). The protective effect of high wealth diminished from 2015 onwards but persisted for high maternal education. However, an intersection of higher household wealth and maternal education mitigated stunting to a greater extent than either factor in isolation. Residence only predicted stunting in 2005-2006 with an urban disadvantage (adjusted OR: 1.18; 95% CI: 1.07 to 1.29). Children from marginalised social groups displayed increased likelihoods of stunting, from 6-16% in 2005-2006 to 11-21% in 2015-2016 and 2020-2021. Being male was associated with 6% and 7% increased odds of stunting in 2015-2016 and 2019-2021, respectively. Increased household wealth (45%) and maternal education (14%) contributed to decreased stunting prevalence between 2005 and 2021.

Conclusions

Stunting prevalence in India has decreased across social groups. However, social disparities in stunting persist and are exacerbated by intersections of low household wealth, maternal education and being from a marginalised social group. Increased survival must be accompanied by needs-based interventions to support children and mitigate mutually reinforcing sources of inequality.

Undernutrition and anaemia among Indian adolescents: role of dietary diversity and hygiene practices

In 2021, the Lancet Commission on adolescent nutrition highlighted the need to prioritise the elimination of adolescent malnutrition to tap the human capital potential and break the intergenerational malnutrition trap. The nutritional requirement during adolescence reaches its peak. The present study aims to appraise the prevalence of undernutrition (stunting and thinness) and anaemia among adolescents (10–19 years) in India and the role of socioeconomic, individual-level hygiene behaviour and dietary diversity in nutritional outcomes. We have used the nationally representative Comprehensive National Nutrition Survey (CNNS-2016–18) that covers children and adolescents (0–19 years) in India. The prevalence of stunting, anaemia and thinness among adolescents was 27⋅2, 28⋅5 and 24⋅1 %, respectively. Bivariate and multivariable logistic regression models were applied to estimate the likelihood of undernutrition. The likelihood of stunting was higher for late adolescence (OR 1⋅21, 95 % CI 1⋅15, 1⋅27), low dietary diversity (OR 1⋅37, 95 % CI 1⋅26, 1⋅49) and low hygiene behaviour compliance (OR 1⋅53, 95 % CI 1⋅42, 1⋅64). Adolescents from the poorest quintile were more likely to be stunted (OR 3⋅20, 95 % CI 2⋅94, 3⋅48), anaemic (OR 1⋅66, 95 % CI 1⋅47, 1⋅87) and thin (OR 1⋅68, 95 % CI 1⋅54, 1⋅82). We found that lower hygienic compliance was significantly associated with undernutrition and anaemia. Therefore, promoting hygienic practices should be emphasised to tackle undernutrition and anaemia. Furthermore, dietary diversity and poverty were strong predictors of stunting and thinness, therefore targeting the poor and focusing on improving dietary diversity should be the priority.

Stories of change in nutrition: lessons from a new generation of studies from Africa, Asia and Europe

How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded experiential learning across contexts. This article provides an overview of findings from 14 studies undertaken in nine countries in South Asia, sub-Saharan Africa, and Europe between 2017 and 2021. The studies used a combination of methods, including regression-decomposition analyses of national datasets to assess determinants of nutritional change; policy process and food environment analyses; and community-level research assessing attitudes to change. This article takes a narrative synthesis approach to identify key themes across the studies, paying particular attention to multisectoral determinants, changes in the food environment, the role of structural factors (including longstanding social inequities), and changes in political commitment, cross-sectoral coherence and capacity. Given the inherent multisectoral nature of nutrition, many countries are experimenting with different models of ensuring coherence across sectors that are captured in this body of work. The relative immaturity of the policy sector in dealing with issues such as obesity and overweight, and associated influences in the wider food environment, adds a further challenge. To address these interrelated issues, policy must simultaneously tackle nutrition's upstream (social/economic/equity) and downstream (health and dietary) determinants. Studies synthesised here provide empirically-driven inspiration for action.

Implementation Outcomes of National Convergence Action Policy to Accelerate Stunting Prevention and Reduction at the Local Level in Indonesia: A Qualitative Study

The study aims to explore the implementation outcome variables of Indonesia's national policy convergence action in the stunting reduction intervention at district, sub-district, and village levels. The study design was qualitative with an implementation research approach at District Cirebon, Indonesia. Data were collected through in-depth interviews, focus group discussions, study documents, and 6 months of participant observation. We recruited 172 respondents. The assessment instrument used was formed on was implementation outcomes variables. Data were analyzed through coding, categorizing and thematic content analysis based on a predetermined theme. Comparative cross district activity-site analysis was applied between sub-districts and villages. The implementation outcome variables for the convergence action policy were performed well at the district level, in line with the central government's adequate regulation, control, and budget. Meanwhile, the sub-district and village levels only performed aspects of acceptability, appropriateness, and coverage for specific interventions. The acceptability level in the village was only partially running. The barriers at the sub-district and village levels were issues of commitment, staff capacity, and poor coordination. Superficial understanding and capacity weaknesses drove the convergence of the stunting reduction responsibility back into the burden of the health sector at the forefront. Local politics also colored the implementation in the village.

Understanding the Change in the Prevalence and Factors Influencing the Childhood Stunting Using District-Level Data from NFHS-4 and NFHS-5 in India

To compare the district level prevalence of childhood stunting between NFHS-4 and NFHS-5 and to explore the correlates of it at the district level. Although malnutrition rates in India have decreased over a period, country is still a home for the highest number of stunted and wasted children in the world. Among the South Asian countries, India has the second highest number of stunted children. An ecological study conducted by using the data from fourth and fifth round of National Family Health Survey. Study concentrated on percentage of children who were stunted across 692 Indian districts during 2 survey periods and its correlates from NFHS-5. District level change in childhood stunting was calculated by differencing the NFHS-5 estimates from NFHS-4. Descriptive statistics were used to understand the nature of the variables and Moran’s I statistic was calculated to check for the spatial autocorrelation in the childhood stunting. Spatial error regression model was used to identify the correlates of childhood stunting. Among the Indian districts considered, 243 districts showed the increase in childhood stunting between the time periods considered. Currently, about 33.56% of children in India are stunted and there is high spatial disparity in the prevalence of childhood stunting among the districts of it. Major hotspots of childhood stunting were found in the parts of UP, Bihar, Jharkhand, and West Bengal. Households access to improved sanitation facility, iodized salt, clean fuel, women 10 plus years of schooling, post-natal care of mother were found to be the significant protective factors. Closed spacing of births, teenage pregnancy, low BMI of women, childhood diarrhea, and anemia were found to be the significant risk factors of childhood stunting. Stunting depends on several other factors apart from poverty, working on these factors will help in reducing childhood stunting in India.