Early life mortality and height in Indian states

Exploring the paradox of Muslim advantage in undernutrition among under-5 children in India: a decomposition analysis

BACKGROUND

While there is a substantial body of research on inequalities in child nutrition along the axes of gender and socioeconomic gradient, the socio-religious differences in health and nutrition outcomes remain grossly understudied. The handful of studies on the socio-religious differential in child health outcomes has found a Muslim advantage in chances of survival and nutritional status over Hindus despite their comparatively lower socioeconomic status, which undeniably warrants investigating the pathways through which this paradoxical Muslim advantage manifests.

METHODS

Using data from the National Family Health Survey, 2015-16, we quantify the inter-group differentials in child undernutrition (stunting, wasting, and underweight) between Muslims and caste-disaggregated Hindus. We further decompose the gap to delineate its major contributory factors by employing Fairlie's decomposition method.

RESULTS

The analysis revealed that, compared to the Hindus as an aggregated group, Muslims have a higher rate of stunting and lower rates of wasting and being underweight. However, the differences get altered when we disaggregate the Hindus into high and low castes. Muslims have a lower prevalence of all three measures of undernutrition than the low-caste Hindus and a higher prevalence of stunting and underweight than the high-caste Hindus, consistent with their levels of socioeconomic status. However, the prevalence of wasting among Muslim children is lower than among high-caste Hindus. This nutritional advantage is paradoxical because Muslims' relatively poorer socioeconomic status compared to high-caste Hindus should have disadvantaged them. In the decomposition analysis, the Muslim advantage over the low-caste Hindus could only be partially attributed to the former's better economic status and access to sanitation. Moreover, the poor performance of Muslim children compared to the high-caste Hindus in stunting and underweight could mainly be explained by the religious differentials in birth order, mother's education, and wealth index. However, Muslim children's comparatively better performance in wasting than the high-caste Hindus remained a puzzle.

CONCLUSION

The Muslim advantage over high-caste Hindus in wasting and low-caste Hindus in all the indicators of undernutrition may have been rendered by certain 'unobserved' behavioural and cultural differences. However, further exploration is needed to make a definitive claim in this respect.

Mothers' Social Status and Children's Health: Evidence From Joint Households in Rural India

The premise that a woman's social status has intergenerational effects on her children's health has featured prominently in population science research and in development policy. This study focuses on an important case in which social hierarchy has such an effect. In joint patrilocal households in rural India, women married to the younger brother are assigned lower social rank than women married to the older brother in the same household. Almost 8% of rural Indian children under 5 years old-more than 6 million children-live in such households. We show that children of lower-ranking mothers are less likely to survive and have worse health outcomes, reflected in higher neonatal mortality and shorter height, compared with children of higher-ranking mothers in the same household. That the variation in mothers' social status that we study is not subject to reporting bias is an advantage relative to studies using self-reported measures. We present evidence that one mechanism for this effect is maternal nutrition: although they are not shorter, lower-ranking mothers weigh less than higher-ranking mothers. These results suggest that programs that merely make transfers to households without attention to intrahousehold distribution may not improve child outcomes.

Did parental care in early life affect height? Evidence from rural Spain (19th-20th centuries)

This article examines the relationship between childhood mortality experienced within families and the height of surviving male children. Sibling mortality, controlled by different socioeconomic and environmental variables, is used as an approximation of the hygienic and epidemiological context and practices within the family. The analysis is based on a sample of 2783 individuals born between 1835 and 1977 in 14 villages in north-eastern Spain. The mortality data were obtained from the parish archives of the reference villages, and the height data from military service records of conscriptions at 21 years of age. The data were linked according to nominative criteria using family reconstitution methods. The results suggest the existence of a strong negative relationship between height and the childhood mortality experienced within families. Children born in families in which 50% of the children died before the age of five were up to 2.3 cm shorter than those of families with childhood mortality of less than 25%. General socioeconomic, hygienic and health improvements reduced childhood mortality, causing this link to gradually disappear between the 1940s and 1970s.

NEONATAL DEATH IN INDIA: BIRTH ORDER IN A CONTEXT OF MATERNAL UNDERNUTRITION

We document a novel fact about neonatal death, or death in the first month of life. Globally, neonatal mortality is disproportionately concentrated in India. We identify a large effect of birth order on neonatal mortality that is unique to India: later-born siblings have a steep survival advantage relative to the birth-order gradient in other developing countries. We show that India's high prevalence of maternal undernutrition and its correlation with age and childbearing can explain this pattern. We find that Indian mothers exit the underweight body mass range at an internationally comparatively high rate as they progress through childbearing careers.

One size does not fit all. How universal standards for normal height can hide deprivation and create false paradoxes

Public health practitioners and social scientists frequently compare height against one-size-fits-all standards of human growth to assess well-being, deprivation, and disease risk. However, underlying differences in height can make some naturally tall populations appear well-off by universal standards, even though they live in severe states of deprivation. In this article, I describe the worldwide extent of these population differences in height and illustrate how using a universal yardstick to compare population height can create puzzling disparities (eg, between South Asia and sub-Saharan Africa) while also underestimating childhood stunting in specific world regions (eg, West Africa and Haiti). I conclude by discussing potential challenges of developing and implementing population-sensitive standards for assessing healthy development.

Political violence, adverse shocks and child malnutrition: Empirical evidence from Andhra Pradesh, India

We analyze the combined effect of political violence and adverse climatic and health shocks on child nutrition using longitudinal data from Andhra Pradesh, India. The paper shows three key results using two-stage least square (2SLS) models: (i) the presence of political violence reduces the mean height-for-age z-scores of children by between 0.4 and 0.9 standard deviations and reduces the mean weight-for-age z-scores of children by between 0.3 and 0.6 standard deviations; (ii) political violence generates such a large negative effect on the long-term nutrition of children (measured by height-for-age z-scores) through a reduction of the ability of households to cope with drought and illness; and (iii) drought and illness have an adverse effect on child nutrition in Andhra Pradesh only in violence-affected communities. The 2SLS results are robust to a wide range of robustness tests. Potential mechanisms explaining the strong joint welfare effect of conflict and adverse shocks are the failure of economic coping strategies in areas of violence and restricted access to public goods and services.

The relationship between adult height and diabetes in India: A countrywide cross-sectional study

BACKGROUND

One major aspect of the epidemiological transition happening in India is the increased diabetes prevalence. Poor environmental conditions in early childhood potentially can increase the risk of developing diabetes in adulthood. Adults' height as an indirect indicator might reflect such conditions. In this paper, we investigate the relationship between adult height as a proxy for early childhood conditions and the risk of developing diabetes in India.

METHODS

This cross-sectional study used national representative data of the latest National Family Health Survey (2015-2016), comprising 512 616 women aged 20 to 49 and 87 281 men aged 20 to 54. We applied the multivariable fractional polynomials approach in logistic regression models to allow for nonlinear relationships between height and diabetes, separated by sex. Additionally, we fitted logistic regression models with height categories. Fixed effects linear probability models were used to control for potential confounding.

RESULTS

The study revealed a linear relationship between increasing height and increasing diabetes risk among men. Among women, the shortest were at the highest risk (not significant).

CONCLUSIONS

Among Indian men, being taller increases the risk of developing diabetes, which contradicts findings from other countries. In contrast, the shortest women seem to be at the greatest risk. Hence, public health interventions in India might be well advised to focus more on the nutrition status of young girls.

Changes in Child Nutrition in India: A Decomposition Approach

BACKGROUND

Improvements in child health are a key indicator of progress towards the third goal of the United Nations' Sustainable Development Goals. Poor nutritional outcomes of Indian children are occurring in the context of high economic growth rates. The aim of this paper is to conduct a comprehensive analysis of the demographic and socio-economic factors contributing to changes in the nutritional status of children aged 0-5 years in India using data from the 2004-2005 and 2011-2012 Indian Human Development Survey.

METHODS

To identify how much the different socio-economic conditions of households contribute to the changes observed in stunting, underweight and the Composite Index of Anthropometric Failure (CIAF), we employ both linear and non-linear decompositions, as well as the unconditional quantile technique.

RESULTS

We find the incidence of stunting and underweight dropping by 7 and 6 percentage points, respectively. Much of this remarkable improvement is encountered in the Central and Western regions. A household's economic situation, as well as maternal body mass index and education, account for much of the change in child nutrition. The same holds for CIAF in the non-linear decomposition. Although higher maternal autonomy is associated with a decrease in stunting and underweight, the contribution of maternal autonomy to improvements is relatively small.

CONCLUSIONS

Household wealth consistently makes the largest contribution to improvements in undernutrition. Nevertheless, maternal autonomy and education also play a relatively important role.

Early life environment and adult height: The case of Chile

In this paper, we analyze the relationship between adult height and early-life disease environment, proxied by the infant mortality rate (IMR) in the first year of life, using cohort-region level data for Chile for 1960-1989. IMRs show a remarkable reduction of 100 points per thousand over this thirty-year period, declining from 119.4 to 21.0 per thousand. We also document a 0.96 cm increase in height per decade.We find that the drop in IMRs observed among our cohorts explains almost all of the long-term trend in rising adult heights, and that per capita GDP does not appear to have any predictive power in this context. Results are robust in a variety of specifications, which include area and cohort dummies, an adjustment for internal migration, and urbanization rates. Our results point to the long-term effect of a public health policy.

Parental human capital and child health at birth in India

Health at birth shapes an individual's well-being over her life cycle. We categorize the Indian states into high and low infant mortality regions to capture the diverse disease environment and analyze the nature of the association between parental human capital and child survival and nutrition measures at birth. We restrict our analysis only to firstborns to avoid confounding from a number of factors including sex-selective abortions in the higher birth orders. We broadly find that parental human capital, especially maternal health, is a strong and significant predictor of a child's birth outcomes under adverse disease environment. In the rural areas of the high infant mortality states, a 10-centimeter increase in maternal height is associated with 1.7% lower probability of a child dying as a neonate and 5% increase in birth weight around the mean. These estimates suggest that an investment in human capital of the mothers from this region could accompany large gains in survival and nutrition outcomes of their children.

Child Height in India: Facts and Interpretations from the NFHS-4, 2015-16

An analysis of child height-for-age using the newly released data from the National Family Health Survey-4 indicates that the average child height increased by about four-tenths of a height-for-age standard deviation between 2005 and 2015. Although important, this increase is small relative to India's overall height deficit, and relative to economic progress; children in India remain among the shortest in the world. It is unsurprising that the increase in height-for-age has been modest because none of the principal factors responsible for India's poor child height outcomes have substantially improved over the last decade. Familiar patterns of regional, sex, and caste disadvantage are reflected in child height in 2015.

Public health and multiple-phase mortality decline: Evidence from industrializing Japan

A growing body of literature shows the mitigating effects of water-supply systems on the mortality rates in large cities, yet the heterogeneities in the effects have been understudied. This study fills in the gap in existing knowledge by providing evidence for non-linearity in the effects of clean water using semiparametric fixed effects approach with city-level nationwide longitudinal dataset between 1922 and 1940, which covers 91% of total city population. According to our baseline estimate, the clean water accounts for approximately 27% of the decrease in the crude death rate in this period. Our results also indicate the heterogeneities in the improving effects of clean water with respect to the coverage of tap water among citizens. We found evidence that the installation of the water-supply system itself decreased waterborne infections and infant mortality but did not substantially improve the overall mortality rate in the initial phase. However, the subsequent expansion of tap water could result in a continuous decline in the overall risk of deaths in the second phase.

Association between infection burden and adult height

Although highly heritable, adult height is also associated with numerous environmental factors, including exposure to infection. Particularly in developing regions of the world, infection burden appears to slow growth during childhood. Using a large database representative of the US population, we examined associations between adult height and leg length and an infection-burden index based on past exposure to Toxocara species, Toxoplasmosis gondii, cytomegalovirus, hepatitis A, hepatitis B, hepatitis C, herpes simplex virus 1, and herpes simplex virus 2. In models controlled for age, sex, educational attainment, socioeconomic status, and race-ethnicity, we found that the infection-burden index predicted height (β=-0.10 [95% CI: -0.15, -0.05], p .001<0.001) but not leg length (β=-0.04 [95% CI: -0.12, 0.04], p=0.357). Both sex and race-ethnicity moderated this association. In addition, exposures to Toxocara species, cytomegalovirus, and hepatitis A were each individually associated with reduced height and reduced leg length. While associations between growth and infection have been found principally in children in developing regions of the world, our findings suggest that the effects of infection on height may persist into adulthood even in developed nations.

Child height and intergenerational transmission of health: Evidence from ethnic Indians in England

A large literature documents a widespread prevalence of small stature among Indian children as well as adults. We show that a height gap relative to a richer population such as whites in England also exists, although substantially reduced, among adult immigrants of Indian ethnicity in England. This is despite positive height selection into migration, demonstrated by ethnic Indian adults in England being on average 6-7cm taller than in India. However, the difference between natives and ethnic Indians in England disappears among their younger sons and daughters, although it re-appears among adolescents. We estimate that, conditional on age, gender and parental height, ethnic Indian children of age 2-4 in England are 6-8% taller than in India. Such degree of catch up in one generation is remarkable, also because in England children of ethnic Indians have much smaller birthweight than whites, by about 0.4kg on average.

Economics, human biology and inequality: A review of "puzzles" and recent contributions from a Deatonian perspective

The Nobel laureate Angus Deaton concentrated his work on puzzling developments and phenomena in economics. Puzzles are exciting elements in economics, because readers feel challenged by the question of how they can be solved. Among the puzzles analyzed by Deaton are: (1) Mortality increase of white, U.S. non-Hispanic men (2000 to today); (2) Why are height and income sometimes closely correlated, but not always?; (3) Height inequality among males and females; and (4) The Indian puzzle of declining consumption of calories during overall expenditure growth. This article reviews these "puzzles" and the main insights that Deaton derived from their discussion insofar as they pertain to the biological aspects of human development. I will focus on the field of this journal, Economics and Human Biology, in which Deaton has been very active over the last two decades. I will also document some of the responses by other scholars and their contributions to these puzzles, as they relate to the field of economics and human biology.

Do boys eat better than girls in India? Longitudinal evidence on dietary diversity and food consumption disparities among children and adolescents

This paper examines the dynamics of gender-based disparities in the intra-household allocation of food during childhood and adolescence in Andhra Pradesh and Telangana by using three rounds of longitudinal data from two cohorts. While boys are advantaged at all ages (except for the Younger Cohort at 12 years old), the pro-boy gap widens markedly at 15 years old. Specifically, mid-adolescent girls tend to consume fewer protein- and vitamin-rich foods such as eggs, legumes, root vegetables and fruit. This result is robust to gender differences between adolescents in terms of puberty onset, school enrolment, time use and dietary behaviours. Finally, gender disparities in dietary diversity during early and mid-adolescence do not vary by maternal education, poverty or place of residence, whilst they are moderated by levels of caregiver's educational aspirations at 15 years old.

Climatic conditions and child height: Sex-specific vulnerability and the protective effects of sanitation and food markets in Nepal

Environmental conditions in early life are known to have impacts on later health outcomes, but causal mechanisms and potential remedies have been difficult to discern. This paper uses the Nepal Demographic and Health Surveys of 2006 and 2011, combined with earlier NASA satellite observations of variation in the Normalized Difference Vegetation Index (NDVI) at each child's location and time of birth to identify the trimesters of gestation and periods of infancy when climate variation is linked to attained height later in life. We find significant differences by sex: males are most affected by conditions in their second trimester of gestation, and females in the first three months after birth. Each 100-point difference in NDVI at those times is associated with a difference in height-for-age z-score (HAZ) measured at age 12-59 months of 0.088 for boys and 0.054 for girls, an effect size similar to that of moving within the distribution of household wealth by close to one quintile for boys and one decile for girls. The entire seasonal change in NDVI from peak to trough is approximately 200-300 points during the 2000-2011 study period, implying a seasonal effect on HAZ similar to one to three quintiles of household wealth. This effect is observed only in households without toilets; in households with toilets, there is no seasonal fluctuation, implying protection against climatic conditions that facilitate disease transmission. We also use data from the Nepal Living Standards Surveys on district-level agricultural production and marketing, and find a climate effect on child growth only in districts where households' food consumption derives primarily from their own production. Robustness tests find no evidence of selection effects, and placebo regression results reveal no significant artefactual correlations. The timing and sex-specificity of climatic effects are consistent with previous studies, while the protective effects of household sanitation and food markets are novel indications of mechanisms by which households can gain resilience against adverse climatic conditions.

Education, gender, and state-level disparities in the health of older Indians: Evidence from biomarker data

Using new biomarker data from the 2010 pilot round of the Longitudinal Aging Study in India (LASI), we investigate education, gender, and state-level disparities in health. We find that hemoglobin level, a marker for anemia, is lower for respondents with no schooling (0.7g/dL less in the adjusted model) compared to those with some formal education and is also lower for females than for males (2.0g/dL less in the adjusted model). In addition, we find that about one third of respondents in our sample aged 45 or older have high C-reaction protein (CRP) levels (>3mg/L), an indicator of inflammation and a risk factor for cardiovascular disease. We find no evidence of educational or gender differences in CRP, but there are significant state-level disparities, with Kerala residents exhibiting the lowest CRP levels (a mean of 1.96mg/L compared to 3.28mg/L in Rajasthan, the state with the highest CRP). We use the Blinder-Oaxaca decomposition approach to explain group-level differences, and find that state-level disparities in CRP are mainly due to heterogeneity in the association of the observed characteristics of respondents with CRP, rather than differences in the distribution of endowments across the sampled state populations.