Assessing associational strength of 23 correlates of child anthropometric failure: An econometric analysis of the 2015-2016 National Family Health Survey, India

Levels, severity, and determinants of stunting in children 0-59 months in Afghanistan: Secondary analysis of Multiple Indicator Cluster Survey, 2022-23

Childhood stunting is a critical nutritional concern for Afghanistan. Prioritizing development assistance toward child nutrition requires recent estimates on child stunting and timely insights on determinants at national and sub-national levels. This study addresses this gap by estimating the prevalence and determinants of stunting and severe stunting in children under-five using the latest publically available data. The recent wave of Afghanistan Multiple Indicator Cluster Survey (MICS 2022-23) was analyzed to estimate the prevalence of stunting (height-for-age Z-score <-2SD) and severe stunting (<-3SD) by demographic and socioeconomic characteristics. The predictors of stunting and severe stunting outcomes were examined using multivariate logistic regression analyses with four domains of independent variables - child, maternal, and household characteristics and complementary feeding practices. In Afghanistan, 44·5% of children were stunted and 21.6% were severely stunted. The southern region has the highest burden of stunting (55%). Under-five females were less likely to be stunted than males [OR 0·89, 95% CI (0·84, 0·95)]. The likelihood of stunting increased with age of the child. Lack of maternal education, lower wealth quintiles, no exposure of the mother to mass media, and poor dietary diversity were the key predictors of stunting. Determinants of severe stunting mirrored those of stunting, with the additional risk for 24-59 months age group and higher birth order. Socioeconomic status, maternal education, child age, birth order, dietary practices, and geographical location were key determinants of stunting. Targeted interventions addressing poverty, education for women, family planning, and improved nutrition are crucial to reducing childhood stunting in Afghanistan.

Mitigating the Impact of Intergenerational Risk Factors on Stunting: Insights From Seven of the Most Food Insecure Districts in South Africa

A large body of research investigates the determinants of stunting in young children, but few studies have considered which factors are the most important predictors of stunting. We examined the relative importance of predictors of height-for-age z-scores (HAZ) and stunting among children under 5 years of age in seven of the most food-insecure districts in South Africa using data from the Grow Great Community Stunting Survey of 2022. We used dominance analysis and variable importance measures from conditional random forest models to assess the relative importance of predictors. We found that intergenerational and socioeconomic factors-specifically maternal height (HAZ: Coef. 0.02, 95% CI 0.01-0.03; stunting: OR 0.96, 95% CI 0.94-0.98), birth weight (HAZ: Coef. 0.3, 95% CI 0.16-0.43; stunting: OR 0.5, 95% CI 0.35-0.72) and asset-based measures of socioeconomic status (HAZ: Coef. 0.17, 95% CI 0.10-0.24; stunting: OR 0.77, 95% CI 0.67-0.89)-were the most important predictors of HAZ and stunting in these districts. We explored whether any other factors moderated (weakened) the relationship between these intergenerational factors and child height using conditional inference trees and moderation analysis. We found that being on track for vitamin A and deworming, adequate sanitation, a diverse diet and good maternal mental health moderated the effect of birth weight or mother's height. Though impacts are likely to be small relative to the impact of intergenerational risk factors, these moderating factors may provide promising avenues for helping to mitigate the intergenerational transmission of stunting risk in South Africa.

Ethnicity/caste and child anthropometric outcomes in India using the National Family Heath Survey 2015-16 and 2019-21

Socioeconomic inequalities are known to negatively impact anthropometric outcomes among children, particularly in developing countries. This study, therefore, assesses the gap in anthropometric outcomes of children 6-59 months along the ethnicity-based social groups in India using the National Family Heath Survey 2015-16 and 2019-21. The paper utilizes logistic regression models, the exogenous switching treatment effect regression (ESTER) model, and the Blinder-Oaxaca Model to disentangle the role of ethnicity (referred to as caste in India) in influencing child anthropometric outcomes while accounting for socio/economic factors. Approximately 35% of children in the sample were stunted and 20% wasted. Result indicates that despite the progress made in reducing child undernutrition between the two survey periods, there is a higher risk of chronic growth faltering (stunting) and underweight in socially disadvantageous groups, and these ethnicity-based disparities exist independent of education and household economic status. To improve children's nutritional status, India needs to develop new nutrition strategies prioritizing double-duty action due to the persistence of undernutrition and rising overweight/obesity among children. The study suggests a need for a distinguished understanding of the underlying causes of chronic and acute forms of malnourishment, and separate interventions are required to reduce the disparities among disadvantaged groups, particularly in tribal communities.

Undernutrition Among the Children from Different Social Groups in India: Prevalence, Determinants, and Transition Over Time (2005-2006 to 2019-2021)

Combating undernutrition among children under 5 years is presently an enormous challenge for India. The study aims to determine the prevalence of undernutrition by the Composite Index of Anthropometric Failure (CIAF) and the time-dependent significant determinants of undernutrition among children under 5 years from four recognized social groups, i.e., Scheduled Tribe (ST), Scheduled Caste (SC), Other Backward Class (OBC), and Others, or General group, between 2005-2006 and 2019-2021 in India. It also explains the transition in the probability of CIAF among ST, SC, OBC, and General children belonging to different socio-demographic, economic backgrounds, and geographic regions from 2005-2006 to 2015-2016, 2015-2016 to 2019-2021, and 2005-2006 to 2019-2021 in India. Time-dependent and time-independent logistic regression models are employed to identify the major determinants and predicted probabilities of CIAF, respectively, among four social groups. The predicted probabilities of CIAF among ST, SC, OBC, and General children belonging to various socio-demographic, economic backgrounds, and geographic regions are extracted from logistic regression models and represented graphically. The study outlines a higher prevalence of CIAF among ST children, followed by SC, OBC, and General children throughout the last 15 years. Since 2005-2006, the magnitude of CIAF risk elimination has been comparatively higher among socially marginalized children (ST, SC, OBC) than in General. The investigation also outlines a significant (p < 0.001), and consistent effect of child age, maternal nutritional level, education status, household economic status, and geographic regions on the prevalence of undernutrition among all four social groups in India from 2005-2006 to 2019-2021. The policymakers must focus much on the ST, SC, and OBC sections for eliminating childhood undernutrition. Specifically, more attention is needed for the ST, SC, and OBC children living with non- or less-educated mothers, belonging to poor families, living in central, western, and eastern Indian states for eliminating the childhood CIAF. This might contribute to lowering intergroup inequality (SDG 10.2) in India in terms of the incidence of hunger (SDG 2.2), undernutrition, and child mortality (SDG 3.2).

Deconstructing the sex gap in child undernutrition in India: Are Indian boys at elevated risk of anthropometric failure than the girls?

BACKGROUNDS & OBJECTIVES

The privileging of boys in immunization coverage, breastfeeding, and other child care practices in Indian patriarchal society raises questions about whether there are sex differences in the prevalence of undernutrition among children. This study evaluates the sex gap in the prevalence of Composite Index of Anthropometric Failure (CIAF) among Indian children from 2015-16 to 2019-21. Additionally, it seeks to identify the sex-specific determinants and persistent sex gap at national and subnational levels (social, economic, religious, and geopolitical regions) in anthropometric failure among the children from 2015-16 to 2019-21.

MATERIALS AND METHODS

The study utilizes the 4th (2015-16) and 5th (2019-21) rounds of the National Family Health Survey data. Logistic regression models and the Fairlie decomposition technique were employed to explore the persistent and significant sex gap in the prevalence of CIAF, as well as the sex-specific determinants of CIAF among children in 2015-16 and 2019-21.

RESULTS

The study reveals a significant sex gap (approximately 4%-points), with boy's disadvantage in the prevalence of CIAF from 2015-16 to 2019-21 at both the national and subnational levels (social, religious, socioeconomic groups, and geopolitical regions). The gap is more pronounced in the first year of life and decreases in later stages. A comparatively faster CIAF decline among girls from 2016 to 2021 has widened the sex gap in final year than the previous. Child, mother, household, community, and geographic backgrounds explains about 5%-6% of the sex gap in the prevalence of CIAF from 2015-16 to 2019-21. The remaining 94%-95% of the unexplained sex gap may be attributed to biological factors or other factors. Currently, a heightened boy's disadvantage in CIAF risk is observed in ST community, wealthiest families, and the northern India.

CONCLUSION

The findings suggest a special attention for boys under 3 years to offset biological disadvantages like greater disease sensitivity and fragility compared to girls early on.

Health impact evaluation of Aspirational Districts Program in India: Evidence from National Family Health Survey

The Aspirational District Program (ADP) is a unique initiative of Government of India launched in 2018 that aims to reduce inter-district multidimensional inequality. ADP aims to bring the least developed districts to catch up with the rest of the other districts in the country. The program is comprehensive in its scope as it targets improvement of several key development indicators spanning health and nutrition, education, agriculture and water resources, financial inclusion and skill development and basic infrastructure indicators. Aspirational districts (ADs) are eligible for enhanced funding and priority allocation of various initiatives undertaken by the central and the state governments. Our research estimates the causal impact of ADP on the targeted health and nutrition indicators using a combination of propensity score matching and difference-in-differences (PSM-DID). We use the fourth and fifth rounds of National Family Health Survey (NFHS) data collected in 2015-16 and 2019-21 respectively which serve as the pre and post-treatment data for our analysis. Moreover, we take advantage of the transparent mechanism outlined for the identification of ADs under ADP, which we use for propensity score matching for our PSM-DID. While we observe negative impact of ADP on early initiation of breastfeeding, we believe that the impact is confounded with the effects of Covid-19 since part of NFHS-5 data was collected during the pandemic. However, the negative impact of ADP on early initiation of breastfeeding disappears when we only use pre-covid data (i.e. data for districts from states surveyed before the pandemic). Additionally, using pre-covid data we find a reduction in the prevalence of underweight children younger than 5 years to an extent of 2 to 4 percentage points in ADs as an impact of ADP, which is robust across multiple specification. We do not find evidence of a positive or a negative impact of ADP on any other health and nutrition indicators. Future research efforts should be made towards impact evaluation of all the targeted indicators in order to get a comprehensive unbiased evaluation of ADP.

Household food insecurity, dietary diversity with undernutrition among children younger than five years in Indian subcontinent-a narrative review

The emerging predictors of childhood undernutrition include household food insecurity (HFI) and inadequate diet diversity (DD). Geographical, socio-cultural, economic, and demographic factors contribute to HFI. Earlier, HFI was often considered an outcome of hunger and poverty leading to undernutrition. The increasing availability of data related to childhood DD and its direct association with undernutrition indicates that DD could mediate the relationship between HFI and undernutrition. This narrative review examined the association of HFI and/or DD with undernutrition in children younger than 5 years in the Indian subcontinent; and the current programmes and policies. The current evidence showed a possible association between HFI and DD either independently or together with childhood undernutrition. Until now, nutrition-specific interventions to address moderate and severe forms of undernutrition were focused, with a limited attention on nutrition-sensitive approaches to improve HFI and DD. Interventions which improve HFI and DD may be included in the existing programmes and would help address the undernutrition in children younger than 5 years.

Impact of indoor Air Pollution on the Linear growth of children in Jimma, Ethiopia

BACKGROUND

Stunting in children is the term for reduced linear growth and development, which is frequently brought on by a persistently inadequate diet, recurrent infections and chronic diseases or poor health conditions. Apart from the classic covariates of stunting, which include diet and illness, the relative contribution of household air pollution to chronic nutrition conditions is least studied. Hence, this study is conducted to investigate the impact of household air pollution on the linear growth of under-five children in Jimma town, Ethiopia.

METHODS

A prospective cohort study was employed to collect data from 280 under-five children who lived in households using solid fuel (exposed group, n = 140) and clean fuel (unexposed group, n = 140). Height-for-age Z scores were compared in both groups over a 12-month follow-up period. The difference in differences estimators were used for comparison of changes in the height-for-age Z scores from baseline to end line in exposed and non-exposed groups. The independent effect of the use of solid fuels on height-for-age Z scores was analyzed through a multivariable linear regression model. Statistical Significances were declared at P < 0.05 and 95% CI level.

RESULTS

In an unadjusted model (Model 1), compared with the clean fuel type, the mean difference in the height-for-age Z score of children in households using solid fuel was lower by 0.54 (-0.54, 95% CI -0.97, -0.12, P = 0.011). The beta coefficient remained negative after adjusting for age and sex (Model 2 -0.543, 95% CI -1.373, -0.563) and sociodemographic variables (Model 3: -0.543, 95% CI -1.362, -0.575). In the final model (Model 4), which adjusted for wealth quantile, dietary practice, water, sanitation and hygiene status and household food insecurity access scale, the beta coefficient held the same and significant (beta: -0.543, 95% CI -1.357, -0.579, P < 0.001). Higher HAZ scores were observed among female child (β: = 0.48, 95%CI: 0.28, 0.69), Child with father attended higher education (β: = 0.304 95%CI: 0.304, 95% CI 0.19, 0.41) as compared to male gender and those who did not attend a formal education, respectively. In contrast, child living in households with poor hygiene practices had lower HAZ score (β: -0.226, 95% CI: -0.449, -0.003), P < 0.001.

CONCLUSIONS

Exposure to indoor air pollution was inversely related to linear growth. Furthermore, sex, educational status and hygiene were found relevant predictors of linear growth. In such a setting, there is a need to step up efforts to design and implement public education campaigns regarding the health risks associated with exposure to household air pollution. Promoting improvements to kitchen ventilation and the use of improved cooking stoves, which will help to mitigate the detrimental effects of indoor air pollution on child growth impairment and its long-term effects.

Economic Growth and Childhood Malnutrition in Low- and Middle-Income Countries

Importance

Economic growth may reduce childhood malnutrition through improvements of several contributing factors, but the empirical evidence is mixed. Identifying the most important factors that contribute to child malnutrition and their associations with economic growth can inform decision-making about targeted investments to improve children's health.

Objective

To assess the associations between economic growth and malnutrition, contributing factors and malnutrition, and economic growth and contributing factors of malnutrition in low- and middle-income countries (LMICs).

Design, Setting, and Participants

This cross-sectional study used data from 239 Demographic and Health Surveys from January 1, 1990, to December 31, 2021. Observations included 1 138 568 children aged 0 to 35 months with valid anthropometric measures and information on contributing factors of malnutrition from 58 LMICs. Data were analyzed from May 20, 2022, to February 16, 2023.

Exposure

National per-capita gross domestic product (GDP) was used as a proxy for economic growth.

Main Outcomes and Measures

Six measures of childhood malnutrition were constructed: stunting (height-for-age z score <-2), underweight (weight-for-age z score <-2), wasting (weight-for-height z score <-2), overweight (weight-for-height z score >2), obesity (weight-for-height z score >3), and dietary diversity failure (consumption of less than 5 of 8 different food groups in the past 24 hours). Eighteen contributing factors of malnutrition were constructed, of which 10 were underlying determinants (eg, access to improved sanitation) and 8 were immediate determinants (eg, breastfeeding initiation).

Results

A total of 1 138 568 children (mean [SD] age, 17.14 [10.26] months; 579 589 [50.9%] boys and 558 979 [49.1%] girls) were included in the analysis. Of these, 27.3% (95% CI, 27.2%-27.4%) had stunting; 25.7% (95% CI, 25.6%-25.8%), underweight; 11.2% (95% CI, 11.1%-11.2%), wasting; 3.8% (95% CI, 3.7%-3.8%), overweight; 1.1% (95% CI, 1.1%-1.1%), obesity; and 79.8% (95% CI, 79.7%-79.9%), dietary diversity failure. Per-capita GDP was weakly associated with childhood malnutrition. The odds ratios associated with a 5% increase in per-capita GDP were 0.99 (95% CI, 0.99-1.00) for stunting, 1.01 (95% CI, 1.00-1.01) for wasting, 1.00 (95% CI, 1.00-1.00) for underweight, 0.98 (95% CI, 0.98-0.98) for overweight, 0.98 (95% CI, 0.97-0.98) for obesity, and 1.03 (95% CI, 1.01-1.04) for dietary diversity failure. Although strong associations were found between many contributing factors and most outcomes for malnutrition, associations identified between per-capita GDP and these contributing factors themselves were ambiguous.

Conclusions and Relevance

In this multicountry cross-sectional study, economic growth was weakly associated with childhood malnutrition and several contributing factors. To reduce child malnutrition, economic growth may need to be accompanied by more targeted investments to improve contributing factors that are strongly associated with child malnutrition, such as maternal health and education.

Patterns in child stunting by age: A cross-sectional study of 94 low- and middle-income countries

Child stunting prevalence is primarily used as an indicator of impeded physical growth due to undernutrition and infections, which also increases the risk of mortality, morbidity and cognitive problems, particularly when occurring during the 1000 days from conception to age 2 years. This paper estimated the relationship between stunting prevalence and age for children 0-59 months old in 94 low- and middle-income countries. The overall stunting prevalence was 32%. We found higher stunting prevalence among older children until around 28 months of age-presumably from longer exposure times and accumulation of adverse exposures to undernutrition and infections. In most countries, the stunting prevalence was lower for older children after around 28 months-presumably mostly due to further adverse exposures being less detrimental for older children, and catch-up growth. The age for which stunting prevalence was the highest was fairly consistent across countries. Stunting prevalence and gradient of the rise in stunting prevalence by age varied across world regions, countries, living standards and sex. Poorer countries and households had a higher prevalence at all ages and a sharper positive age gradient before age 2. Boys had higher stunting prevalence but had peak stunting prevalence at lower ages than girls. Stunting prevalence was similar for boys and girls after around age 45 months. These results suggest that programmes to prevent undernutrition and infections should focus on younger children to optimise impact in reducing stunting prevalence. Importantly, however, since some catch-up growth may be achieved after age 2, screening around this time can be beneficial.

Explaining the poor-rich gap in anthropometric failure among children in India: An econometric analysis of the NFHS, 2021 and 2016

Wealth inequality in anthropometric failure is a persistent concern for policymakers in India. This necessitates a comprehensive analysis and identification of various risk factors that can explain the poor-rich gap in anthropometric failure among children in India. We analyze the fifth and fourth rounds of the Indian National Family Health Survey collected from June 2019 to April 2021 and January 2015 to December 2016, respectively. Two samples of children aged 0-59 and 6-23 months old with singleton birth, alive at the time of the survey with non-pregnant mothers, and with valid data on stunting, severe stunting, underweight, severely underweight, wasting, and severe wasting are included in the analytical samples from both rounds. We estimate the wealth gradients and distribution of wealth among children with anthropometric failure. Wealth gap in anthropometric failure is identified using logistic regression analysis. The contribution of risk factors in explaining the poor-rich gap in AF is estimated by the multivariate decomposition analysis. We observe a negative wealth gradient for each measure of anthropometric failure. Wealth distributions indicate that at least 60% of the population burden of anthropometric failure is among the poor and poorest wealth groups. Even among children with similar modifiable risk factors, children from poor and poorest backgrounds have a higher prevalence of anthropometric failure compared to children from the richest backgrounds. Maternal BMI, exposure to mass media, and access to sanitary facility are the most significant risk factors that explain the poor-rich gap in anthropometric failure. This evidence suggests that the burden of anthropometric failure and its risk factors are unevenly distributed in India. The policy interventions focusing on maternal and child health, implemented with a targeted approach prioritizing the vulnerable groups, can only partially bridge the poor-rich gap in anthropometric failure. The role of anti-poverty programs and growth is essential to narrow this gap in anthropometric failure.

Association of BCC Module Roll-Out in SHG meetings with changes in complementary feeding and dietary diversity among children (6-23 months)? Evidence from JEEViKA in Rural Bihar, India

OBJECTIVES

Child dietary diversity is very low across rural communities in Bihar. Based on the experience of behavior change communication (BCC) module roll out in self-help group (SHG) sessions in rural Bihar, this study aims to assess the impact of the intervention on child dietary diversity levels in the beneficiary groups.

METHODS

The study is based on a pre-post study design whereby child dietary diversity is examined for a sample of 300 children (6-23 months old from 60 village organizations) during both pre-intervention as well as post-intervention phase. The latter consists of two types of group viz. a) children whose mothers were directly exposed to BCC module in SHGs sessions and b) those who were non-participants but may have indirect exposure through spillovers of BCC activities. Econometric analysis including logistic regression as well as propensity score matching techniques are applied for estimating the changes in dietary diversity in the post-intervention phase.

RESULTS

During the pre-intervention phase, 19% of the children (6-23 months) had adequate dietary diversity (eating from at least 4 out of 7 different food groups) and this increased to 49% among the exposed group and to 28% among the non-exposed group in the post-intervention phase. The exposed group have an odds ratio of 3.81 (95% CI: 2.03, 7.15) for consuming diverse diet when compared to the pre-intervention group. The propensity score matching analysis finds a 33% average treatment effect on the treated (ATT) for the group participating in BCC sessions at SHG events.

CONCLUSION

BCC roll out among SHG members is an effective mode to increase dietary diversity among infants and young children. The impact on child dietary diversity was significantly higher among mothers directly exposed to BCC modules. The BCC module also improved knowledge and awareness levels on complementary feeding and child dietary diversity.

Cash transfers and nutrition education to improve dietary diversity among children aged 6-23 months in Grand Gedeh County, Liberia: a cluster-randomized trial

OBJECTIVES

To evaluate the efficacy of a cash transfer and nutrition education program on dietary diversity among children in Liberia. We hypothesized that a multi-pronged intervention would result in improved dietary diversity among children.

METHODS

We conducted a three-armed, cluster-randomized study in 42 communities (12 children per community) in Grand Gedeh County, Liberia, over a 12-month period. We randomly assigned communities to control (n = 14 communities), those that received both bimonthly cash transfers and a structured nutrition education program (n = 14 communities) and those that received bimonthly cash transfers alone (n = 14 communities). Community health assistants conducted bimonthly assessments in participants' homes. The primary outcome was the proportion of children aged 6-23 months who met minimum dietary diversity score (i.e., ≥4 food groups consumed per day). Secondary outcomes included meal frequency and healthcare utilization for illnesses (NCT04101487).

RESULTS

There were 599 children enrolled; 533 (88.9%) were retained through the trial period. The proportion of children who consumed ≥4 food groups per day did not differ among the three arms. However, children randomized to receive cash transfers had higher dietary diversity scores than the control group. Children in communities that received cash transfers alone and with nutrition education consumed significantly more meals per day and were less likely to have visits to clinics or hospitals for illnesses than children in control communities.

CONCLUSION

Bimonthly, unconditional cash transfers and nutrition education were associated with higher dietary diversity scores, greater meal frequency, and fewer healthcare visits for illnesses among children aged 6-23 months.

Intersectional Inequalities in Anthropometric Failure among Indian Children: Evidence from the National Family Health Survey (2015-2016)

Increasing body of health planning and policy research focused upon unravelling the fundamental drivers of population health and nutrition inequities, such as wealth status, educational status, caste/ethnicity, gender, place of residence, and geographical context, that often interact to produce health inequalities. However, very few studies have employed intersectional framework to explicitly demonstrate how intersecting dimensions of privilege, power, and resources form the burden of anthropometric failures of children among low-and-middle income countries including India. Data on 2,15,554 sampled children below 5 years of age from the National Family Health Survey 2015-2016 were analysed. This study employed intersectional approach to examine caste group inequalities in the anthropometric failure (i.e. moderate stunting, severe stunting, moderate underweight, severe underweight, moderate wasting, severe wasting) among children in India. Descriptive statistics and multinomial logistic regression models were fitted to investigate the heterogeneities in the burden of anthropometric failure across demographic, socioeconomic and contextual factors. Interaction effects were estimated to model the joint effects of socioeconomic position (household wealth, maternal education, urban/rural residence and geographical region) and caste groups with the likelihood of anthropometric failure among children.More than half of under-5 children suffered from anthropometric failure in India. Net of the demographic and socioeconomic characteristics, children from the disadvantageous caste groups whose mother were illiterate, belonged to economically poor households, resided in the rural areas, and coming from the central and eastern regions experienced disproportionately higher risk of anthropometric failure than their counterparts in India. Concerted policy processes must recognize the existing heterogeneities between and within population groups to improve the precision targeting of the beneficiary and enhance the efficiency of the nutritional program among under-5 children, particularly for the historically marginalized caste groups in India.

Maternal Height-standardized Prevalence of Stunting in 67 Low- and Middle-income Countries

BACKGROUND

Prevalence of stunting is frequently used as a marker of population-level child undernutrition. Parental height varies widely in low- and middle-income countries (LMIC) and is also a major determinant of stunting. While stunting is a useful measure of child health, with multiple causal components, removing the component attributable to parental height may in some cases be helpful to identify shortcoming in current environments.

METHODS

We estimated maternal height-standardized prevalence of stunting (SPS) in 67 LMICs and parental height-SPS in 20 LMICs and compared with crude prevalence of stunting (CPS) using data on 575,767 children under-five from 67 Demographic and Health Surveys (DHS). We supplemented the DHS with population-level measures of other child health outcomes from the World Health Organization's (WHO) Global Health Observatory and the United Nations' Inter-Agency Group for Child Mortality Estimation. Prevalence of stunting was defined as percentage of children with height-for-age falling below -2 z-scores from the median of the 2006 WHO growth standard.

RESULTS

The average CPS across countries was 27.8% (95% confidence interval [CI], 27.5-28.1%) and the average SPS was 23.3% (95% CI, 23.0-23.6%). The rank of countries according to SPS differed substantially from the rank according to CPS. Guatemala, Bangladesh, and Nepal had the biggest improvement in ranking according to SPS compared to CPS, while Gambia, Mali, and Senegal had the biggest decline in ranking. Guatemala had the largest difference between CPS and SPS with a CPS of 45.2 (95% CI, 43.7-46.9%) and SPS of 14.1 (95% CI, 12.6-15.8%). Senegal had the largest increase in the prevalence after standardizing maternal height, with a CPS of 28.0% (95% CI, 25.8-30.2%) and SPS of 31.6% (95% CI, 29.5-33.8%). SPS correlated better than CPS with other population-level measures of child health.

CONCLUSION

Our study suggests that CPS is sensitive to adjustment for maternal height. Maternal height, while a strong predictor of child stunting, is not amenable to policy interventions. We showed the plausibility of SPS in capturing current exposures to undernutrition and infections in children.

Economic-related inequalities in hepatitis B virus infection among 115.8 million pregnant women in China from 2013 to 2020

BACKGROUND

Hepatitis B virus (HBV) infection is a serious global health problem and China has the largest disease burden. Literatures focusing on economic-related inequalities in HBV infection among pregnant women are scarce. We aimed to quantify the economic-related inequalities and the change over time in HBV infection among pregnant women in mainland China from 2013 to 2020 to inform strategies considering economic-related inequalities.

METHODS

We used national cross-sectional secondary data of pregnant women in 30 provinces from the National Integrated Prevention of Mother-to-Child Transmission of HIV, Syphilis and Hepatitis B Programme (iPMTCT Programme) from 2013 to 2020. We calculated concentration index and adjusted difference between the rich and the poor in the multivariable generalized estimating equation (GEE) model to measure economic-related inequality, after adjusted other risk factors.

FINDINGS

In this study, a total of 115,789,148 pregnant women of mainland China from 2013 to 2020 were included, the overall hepatitis B surface antigen (HBsAg) prevalence was 6.27% (95%CI: 6.26%-6.28%). The curve lay above the equality line, with the negative value of the concentration index of -0.027, which indicated that economic-related health disparities exist in the distribution of HBV infection and the inequality disadvantageous to the poor (pro-poor). The concentration index showed a trend of fluctuating decline, indicating that economic-related inequalities in HBsAg prevalence were narrowing. The adjust difference between counties with lowest economic level and counties with highest economic level (reference group) were 46.3% in HBsAg prevalence (all p<0.05) in the multivariable GEE model, after controlling other confounders. A significant dose-response relationship was observed between low economic level and high HBsAg prevalence that the adjust difference increased from 15.6% (aOR=1.156, 95% CI: 1.064-1.257) in the high-economic group to 46.3% (aOR=1.463, 95% CI: 1.294-1.824) in the lowest-economic group, compared with the highest-economic group. The association between low economic level and high HBsAg prevalence was stable in the sensitivity analysis.

INTERPRETATION

HBV infection was more concentrated among population with lower economic status. Economic-related inequalities in HBV infection decreased in the past decade. Our findings highlight the importance of developing equity-oriented policies and targeted interventions to reduce HBV infection among the poor and hard-to-reach populations to achieve the 2030 HBV elimination goals on time.

FUNDING

National Natural Science Foundation of China.

Eco-geographic patterns of child malnutrition in India and its association with cereal cultivation: An analysis using demographic health survey and agriculture datasets

Background: High prevalence of maternal malnutrition, low birth-weight and child malnutrition in India contribute substantially to the global malnutrition burden. Rural India has disproportionately higher levels of child malnutrition. Stunting and wasting are the primary determinants of child malnutrition and their district-level distribution shows clustering in different geographies and regions. Cereals, particularly millets, constitute the bulk of protein intake among the poor, especially in rural areas in India where high prevalence of wasting persists. Methods: The previous round of National Family Health Survey (NFHS4) has disaggregated data by district, enabling a more fine-scale characterisation of the prevalence of markers of malnutrition. We used data from NFHS4 and agricultural statistics datasets to analyse relationship of prevalence of malnutrition at the district level and area under cereal cultivation. We analysed malnutrition through data on under-5 stunting and wasting by district.  Results: Stunting and wasting patterns across districts show a distinct geographical and age distribution; districts with higher wasting showed relatively higher prevalence at six months of age. Wasting prevalence at district level was associated with higher cultivation of millets, with a stronger association seen for jowar and other millets (Kodo millet, little millet, proso millet, barnyard millet and foxtail millet). District level stunting was associated with higher district level cultivation of wheat. In multivariable analysis, wasting was positively associated with women's body mass index and stunting with women's short stature. Conclusions: Well-designed intervention studies will be required to confirm causal pathways contributing to ecogeographic patterns of child malnutrition. The cultivation of other millets has a strong association with prevalence of wasting. State-of-the-art studies that improve our understanding of bio-availability of amino acids and other nutrients from the prevalent dietary matrices of rural poor communities will be needed to confirm causal pathways contributing to potential eco-geographic patterns.

Small Area Variations in Dietary Diversity Among Children in India: A Multilevel Analysis of 6-23-Month-Old Children

Dietary diversity is an important indicator of child malnutrition. However, little is known about the geographic variation of diet indicators across India, particularly within districts and across states. As such, the purpose of this paper was to elucidate the small area variations in diet indicators between clusters within districts of India. Overall, we found that clusters were the largest source of variation for children not eating grains, roots, and tubers, legumes and nuts, dairy, vitamin A-rich vegetables and fruits, and other vegetables and fruits. We also found positive correlations between the district percent and cluster standard deviations of children not breastfeeding or eating grains, roots, and tubers, but negative correlations between the district percent and cluster standard deviation for the remaining seven outcomes. These findings underscore the importance of targeting clusters to improve child dietary diversity.

Association of Dietary Diversity With Growth Outcomes in Infants and Children Aged Under 5 Years: A Systematic Review

OBJECTIVE

This study aimed to present an overview of the association between dietary diversity (DDiv) and growth outcomes (stunting, wasting, and underweight) in children aged < 5 years.

DESIGN

This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

SETTING AND PARTICIPANTS

PubMed, Scopus, Embase, Cochrane library, and Google Scholar databases were searched up to February, 2021, using relevant keywords as follows: "Dietary diversity or diet diversity or food diversity or diet variety or dietary variety or food variety," "under-nutrition or stunting or wasting or underweight or nutritional status," and "children or infants." Original articles published in English were eligible for this review. Newcastle-Ottawa scales and the Cochrane Collaboration's tool were used to assess the quality and risk of bias of the articles.

MAIN OUTCOME MEASURES, ANALYSIS, AND RESULTS

Totally, 81 articles (70 cross-sectional, 4 longitudinal cohort, 5 case-control, and 2 randomized controlled trials) were included in this review. Of the studies, 45 focused on infants and 36 on children aged < 5 years. The reviewed articles had good quality and low risk of bias (scores > 6). In infants, low DDiv was associated with stunting, wasting, and being underweight (79%, 57%, and 68% of the studies, respectively). Among children aged < 5 years, the association was observed in 75%, 56%, and 57% of the studies, respectively, for stunting, wasting, and underweight.

CONCLUSIONS AND IMPLICATIONS

The findings indicate a possible association between low DDiv of infants and children aged < 5 years with stunting. However, this association remained uncertain with wasting and being underweight.

The Associations between Member of Parliament Characteristics and Child Malnutrition and Mortality in India

Child health outcomes vary between Parliamentary Constituencies (PCs) in India. There are a total of 543 PCs in India, each of which is a geographical unit represented by a Member of Parliament (MP). MP characteristics, such as age, gender, education, the number of terms they have served, and whether they belong to a Scheduled Caste or Scheduled Tribe, might be associated with indicators of child malnutrition and child mortality. The purpose of this paper was to examine the associations between MP characteristics and measures of child malnutrition and mortality. We did not find any meaningful associations between MP characteristics and child anthropometry, anemia, and mortality. Future research should consider the size of a constituency served by an MP along with MP party affiliations as these factors might help explain between-PC variations in child health outcomes. Our findings also underscore the need to better support female MPs and MPs from marginalized caste and tribal groups.

Child nutritional status as screening tool for identifying undernourished mothers: an observational study of mother–child dyads in Mogadishu, Somalia, from November 2019 to March 2020

Background

Active screening of only pregnant and lactating mothers (PLMs) excludes other mothers of reproductive age susceptible to undernutrition. Our analysis evaluated if mothers presenting with wasted children were more likely to be undernourished themselves.

Methods

The observational study enrolled mother and child dyads presenting to an outpatient facility in Mogadishu, Somalia, between November 2019 and March 2020. Trained nurses recorded lower extremity oedema for children aged 6–59 months, parity and gestational status for women aged 19–50 years and age, access to care, height/length, mid-upper arm circumference (MUAC) and weight for both. Weight-for-height z-score (WHZ) for children and body mass index (BMI) for mothers were calculated using standard procedures. Wasting was defined as WHZ <−2, MUAC <12.5 cm and/or presence of oedema for children. Undernutrition was defined as MUAC <23 cm for PLMs and BMI <18.5 kg/m² for neither pregnant nor lactating mothers (non-PLMs). Four multivariable linear regression models were fit to evaluate maternal anthropometric indicators (BMI or MUAC) given child anthropometric indicators (MUAC or WHZ), adjusting for maternal age, parity and gestational status.

Results

A total of 93.6% (2142/2288) of enrolled dyads met inclusion criteria. Wasting was observed among 57.5% of children; 20.2% of pregnant mothers, 20.0% of lactating mothers and 7.95% of non-PLMs were undernourished. Models suggest significant, positive associations between child and maternal anthropometrics; a one-unit increase in WHZ and a 1 cm increase in child MUAC were associated with 0.22 kg/m² (95% CI 0.22 to 0.24) and 0.19 kg/m² (95% CI 0.16 to 0.21) increases in maternal BMI, respectively, and 0.20 cm (95% CI 0.18 to 0.22) and 0.24 cm (95% CI 0.23 to 0.25) increases in maternal MUAC, respectively. Adjusted R² values were low (range 0.06–0.10).

Conclusions

Undernutrition among non-PLMs illustrates the importance of expanding screening. However, while significant, the strength of association between mother and child anthropometrics does not support child nutritional status as a screening tool for identifying at-risk mothers.

Trends of Stunting Prevalence and Its Associated Factors among Nigerian Children Aged 0-59 Months Residing in the Northern Nigeria, 2008-2018

Every year in Nigeria, malnutrition contributes to more than 33% of the deaths of children below 5 years, and these deaths mostly occur in the northern geopolitical zones (NGZs), where nearly 50% of all children below 5 years are stunted. This study examined the trends in the prevalence of stunting and its associated factors among children aged 0-23 months, 24-59 months and 0-59 months in the NGZs. The data of 33,682 recent live births in the NGZs, extracted from the Nigeria Demographic and Health Surveys from 2008 to 2018, were used to investigate the factors associated with stunting using multilevel logistic regression. Children aged 24-59 months reported the highest prevalence of stunting, with 53.3% (95% confidence interval: 52.0-54.6%). Multivariable analyses revealed four common factors that increased the odds of a child's stunting across all age subgroups: poor households, geopolitical zone (northwest or northeast), being a male and maternal height (<145 cm). Interventional strategies focused on poverty mitigation through cash transfer and educating low socioeconomic mothers on the benefits of gender-neutral supplementary feeding and the timely monitoring of the offspring of short mothers would substantially reduce stunting across all age subgroups in the NGZs.

The relative importance of households as a source of variation in child malnutrition: a multilevel analysis in India

Background

Child malnutrition remains a major public health issue in India. Along with myriad upstream and social determinants of these adverse outcomes, recent studies have highlighted regional differences in mean child malnutrition rates. This research helps policy makers look between urban and rural communities and states to take a population-level approach to addressing the root causes of child malnutrition. However, one gap in this between-population approach has been the omission of households as a unit of analysis. Households could represent important sources of variation in child malnutrition within communities, districts, and states.

Methods

Using the fourth round of India’s National Family Health Survey from 2015 to 2016, we analyzed four and five-level multilevel models to estimate the proportion of variation in child malnutrition attributable to states, districts, communities, households, and children.

Results

Overall, we found that of the four levels that children were nested in (households, communities, districts, and states), the greatest proportion of variation in child height-for-age Z score, weight-for-age Z score, weight-for-height Z score, hemoglobin, birthweight, stunting, underweight, wasting, anemia, and low birthweight was attributable to households. Furthermore, we found that when the household level is omitted from models, the variance estimates for communities and children are overestimated.

Conclusions

These findings highlight the importance of households as an important source of clustering and variation in child malnutrition outcomes. As such, policies and interventions should address household-level social determinants, such as asset and social deprivations, in order to prevent poor child growth outcomes among the most vulnerable households in India.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01563-7.

Association of maternal history of neonatal death with subsequent neonatal death across 56 low- and middle-income countries

Early identification of high-risk pregnancies can reduce global neonatal mortality rate. Using the most recent Demographic and Health Surveys from 56 low- and middle-income countries, we examined the proportion of mothers with history of neonatal deaths. Logistic regression models were used to assess the association between maternal history of neonatal death and subsequent neonatal mortality. The adjusted models controlled for socioeconomic, child, and pregnancy-related factors. Country-specific analyses were performed to assess heterogeneity in this association across countries. Among the 437,049 live births included in the study, 6910 resulted in neonatal deaths. In general, 22.4% (1549) occurred to mothers with previous history of neonatal death; at the country-level, this proportion ranged from 1.2% (95% confidence interval [CI] 0.0, 2.6) in Dominican Republic to 38.1% (95% CI 26.0, 50.1) in Niger. Maternal history of neonatal death was significantly associated with subsequent neonatal death in both the pooled and the subgroup analyses. In the fully adjusted model, history of neonatal death was associated with 2.1 (95% CI 1.9, 2.4) times higher odds of subsequent neonatal mortality in the pooled analysis. We observed large variation in the associations across countries ranging from fully adjusted odds ratio (FAOR) of 0.4 (95% CI 0.0, 4.0) in Dominican Republic to 16.1 (95% CI 3.6, 42.0) in South Africa. Our study suggests that maternal history of neonatal death could be an effective early identifier of high-risk pregnancies in resource-poor countries. However, country-specific contexts must be considered in national policy discussions.

Stunting, wasting and underweight as indicators of under-nutrition in under five children from developing Countries: A systematic review

BACKGROUND AND AIMS

To compute reliable estimates of stunting, wasting and underweight along with their determinants in under 5 children from Developing Countries.

METHODS

Out of 190 studies on under-nutrition, accessed from PubMed and Google database, 24 studies meeting the selection criteria were considered for meta-analysis.

RESULTS

Overall estimate of prevalence of stunting, wasting and underweight were 43.4%, 17.8% and 35.5% respectively. Mother's education, BMI, height, wealth index, child birth-weight and sex were factors significantly associated with stunting, wasting and underweight.

CONCLUSIONS

Prevalence of stunting, wasting and underweight in Developing Countries were quite high. To carry-out differentials of under-nutrition between countries and ways of its reduction, more such studies are required.

The legacy of a standard of normality in child nutrition research

Anthropometric evaluation of children is among the most vital and widely used instruments of public health and clinical medicine. Anthropometry is used for establishing norms, identifying variations, and monitoring development. Yet the accurate assessment of physical growth and development of children remains a perpetually beleaguering subject. This paper focuses on the evolution of anthropometry as a science and its associated measurements, indices, indicators, standards, references, and best practices. This paper seeks to clarify aspects of the assessment of child growth, explores the historical trajectory of the study of anthropometry and its contemporary limitations, and contributes to the debate surrounding references and standards, and the applicability of international anthropometric standards to an individual's health. Among its findings is a surprisingly nonlinear and contested record of events, up to and including leading contemporary practices and datasets. It contextualizes the legacy of child malnutrition studies in a broad framework, including the linkage between the early eugenics movement and contemporary notions of a "normal" child, the interpersonal and intuitional competition to become the preeminent child growth authority, the obfuscated distinction between reference growth charts and standards of growth, and the hidden consequences of universal growth standards that no longer reflect any observable populations.

Intersectional role of paternal gender-equitable attitudes and maternal empowerment in child undernutrition: a cross-sectional national study from India

OBJECTIVES

To investigate the role of the intersection of maternal empowerment, paternal gender-equitable attitudes, and household wealth in stunting and severe stunting among underfives in India.

DESIGN

Cross-sectional study.

SETTING

Community-based setting, nationally representative household survey from India.

PARTICIPANTS

We used a sample of 22 867 mother-father-child triads from the fourth round of India's National Family Health Survey (2015-2016). Our inclusion criterion was children below the age of 5 years. The exclusion criterion was a lack of information on paternal gender-equitable attitudes and maternal empowerment. Observations with missing data on any of the covariates were also excluded.

PRIMARY OUTCOME

Stunting and severe stunting among underfives in India.

RESULTS

Our survey-adjusted logistic regression models revealed that even among children from poorer households, those with either an empowered mother or a father with gender-equitable attitudes versus those with none such parents, had a lower odds of stunting (adjusted OR (AOR): 0.92, 95% CI: 0.84 to 1.02) and severe stunting (AOR: 0.87, 95% CI: 0.77 to 0.98), independent of all covariates. We also found substantially lower odds of severe stunting in groups with parental concordance in a woman-friendly outlook, whether non-affluent (AOR: 0.80, 95% CI: 0.67 to 0.94) or affluent (AOR: 0.50, 95% CI: 0.38 to 0.67).

CONCLUSION

We argue that while women's autonomy could reduce the risk of child undernutrition, focusing on men's attitudes towards gender equity also holds promise for reducing undernutrition. Our findings not only underscore how patriarchy is embodied in undernourished children, but also suggest programmatic interventions to address this deep-rooted scourge in India.

The role of the state government, civil society and programmes across sectors in stunting reduction in Chhattisgarh, India, 2006-2016

Introduction

Childhood stunting has declined in India between 2006 and 2016, but not uniformly across all states. Little is known about what helped some states accelerate progress while others did not. Insights on subnational drivers of progress are useful not just for India but for other decentralised policy contexts. Thus, we aimed to identify the factors that contributed to declines in childhood stunting (from 52.9% to 37.6%) between 2006 and 2016 in the state of Chhattisgarh, a subnational success story in stunting reduction in India.

Methods

We examined time trends in determinants of stunting using descriptive and regression decomposition analysis of National Family Health Survey data from 2005 to 2006 and 2015–2016. We reviewed nutrition-relevant policies and programmes associated with the drivers of change to construct a policy timeline. Finally, we interviewed multiple stakeholders in the state to understand the changes in the drivers of undernutrition.

Results

The regression decomposition analysis shows that multiple factors explain 66% of the change in stunting between 2006 and 2016. Improvements in three key drivers—health and nutrition services, household assets, and sanitation and hygiene—explained 47% of the change in stunting. A shared vision for impact, political stability and capable bureaucracy, state-level innovations, support from development partners and civil society, and community mobilisation were found to contribute to improvements in programmes for health, poverty and sanitation.

Conclusion

Change in multiple sectors is important for stunting reduction and can be achieved in subnational contexts. More work lies ahead to close gaps in various determinants of stunting.

Association of Livestock Ownership and Household Dietary Quality: Results from a Cross-Sectional Survey from Rural India

Studies from India and several eastern African countries found that the impact of dairy animal ownership on household nutrition varied greatly, depending on the socio-geographic context. The purpose of this study was to examine the association between livestock ownership and household dietary quality in rural Kolar district, India. We collected data from a household survey in four study villages (n = all 195 households of the four villages) of Kolar district, applying a cross-sectional design. Kendall's rank correlation coefficient was employed to determine the correlation between milk consumption and other dietary variables. Multivariable logistic regression was used to describe the relationship between dairy animal ownership and household milk consumption. Households owning dairy animals more often had access to irrigation (58.3% vs. 25.2%) and were less often woman-headed (2.4% vs. 22.5%). Household milk consumption was significantly correlated with consumption of vegetable variety, egg, and meat (all p-values < 0.05). After adjusting for multiple confounders, the odds ratio of milk consumption between dairy animal-owning households as compared to other households was 2.11 (95% confidence interval 0.85, 5.45). While dairy animal ownership was found to be associated with improved dietary quality, larger households were in a better position to adopt dairy animals, which, in turn, might contribute to better household nutrition.

Multilevel analysis of geographic variation among correlates of child undernutrition in India

Prior research has identified a number of risk factors ranging from inadequate household sanitation to maternal characteristics as important determinants of child malnutrition and health in India. What is less known is the extent to which these individual‐level risk factors are geographically distributed. Assessing the geographic distribution, especially at multiple levels, matters as it can inform where, and at what level, interventions should be targeted. The three levels of significance in the Indian context are villages, districts, and states. Thus, the purpose of this paper was to (a) examine what proportion of the variation in 21 risk factors is attributable to villages, districts, and states in India and (b) elucidate the specific states where these risk factors are clustered within India. Using the fourth National Family Health Survey dataset, from 2015 to 2016, we found that the proportion of variation attributable to villages ranged from 14% to 63%, 10% to 29% for districts and 17% to 62% for states. Furthermore, we found that Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh were in the highest risk quintile for more than 10 of the risk factors included in our study. This is an indication of geographic clustering of risk factors. The risk factors that are clustered in states such as Bihar, Jharkhand, Madhya Pradesh and Uttar Pradesh underscore the need for policies and interventions that address a broader set of child malnutrition determinants beyond those that are nutrition specific.

Association of basic vaccination with cognitive and learning ability among children: insights from the India Human Development Survey, 2004-05 and 2011-12

Basic vaccination is important to protect children from infectious diseases and illnesses. Adequate levels of vaccination coverage reduce the morbidity and mortality burden among children and promote their physical and mental development. This study aimed to assess the association between basic childhood vaccination and the cognitive and learning ability of school children in India. Nationally representative follow-up data on 6183 children from the Indian Human Development Surveys conducted in 2004-05 and 2011-12 (IHDS I & II) were analysed. Children aged 8-10 years who had received all basic vaccines by the age 12 months performed better in a maths test than partially vaccinated or unvaccinated children (OR: 1.87, 95% CI: 1.48, 2.35). Similarly, fully vaccinated children performed better in writing tasks than partially vaccinated or unvaccinated children (OR: 1.77, 95% CI: 1.44, 2.18). Likewise, fully vaccinated children had better reading skills than fully unvaccinated children (OR: 1.60, 95% CI: 1.23, 2.09). The results suggest that enhancing child vaccination coverage can have significant benefits beyond health and can potentially improve the long-term educational outcomes of children.

Cooking, smoking, and stunting: Effects of household air pollution sources on childhood growth in India

This paper investigates the effects of household air pollution (HAP) on child stunting in India using a sample of 206, 898 under-five children from the latest National Family Health Survey (2015-16). Descriptive statistics and multivariate analysis were used to understand the association of stunting by type of cooking fuel, separate kitchen, and indoor smoking in the household. Using clean cooking fuels (CCFs), having a separate kitchen, and being unexposed to smoking can reduce the prevalence of stunting by 4%, 1%, and 1%, respectively, from the current prevalence of stunting (38%). The probability of childhood stunting among children living in households using unclean cooking fuel (UCF) was significantly higher (OR-1.16; 95% CI: 1.13-1.19) than those living in households using CCF. Findings were similar results in the absence of separate kitchen (OR-1.08; 95% CI: 1.05-1.10) and exposure to environmental tobacco smoke (OR-1.06; 95% CI: 1.04-1.08). Households using UCF had a 16% higher likelihood of stunting, while there was a strong gradient of HAP with stunting after controlling socioeconomic and demographic factors. Therefore, the LPG programs, such as the Pradhan Mantri Ujjwala Yojana, may be crucial to reduce HAP and its adverse impact on stunting, and successively to achieve sustainable development goals.

A typology of dietary and anthropometric measures of nutritional need among children across districts and parliamentary constituencies in India, 2016

BACKGROUND

Anthropometry is the most commonly used approach for assessing nutritional need among children. Anthropometry alone, however, cannot differentiate between the two immediate causes of undernutrition: inadequate diet vs disease. We present a typology of nutritional need by simultaneously considering dietary and anthropometric measures, dietary and anthropometric failures (DAF), and assess its distribution among children in India.

METHODS

We used the 2015-16 National Family Health Survey, a nationally representative sample of children aged 6-23 months (n = 67 247), from India. Dietary failure was operationalized using World Health Organization (WHO) standards for minimum dietary diversity. Anthropometric failure was operationalized using WHO child growth reference standard z-score of <-2 for height-for-age (stunting), weight-for-age (underweight) and weight-for-height (wasting). We also created a combined anthropometric measure for children who had any one of these three anthropometric failures. We cross-tabulated dietary and anthropometric failures to produce four combinations: Dietary Failure Only (DFO), Anthropometric Failure Only (AFO), Both Failures (BF), and Neither Failure (NF). We estimated the prevalence and distribution of the four types, nationally, and across 640 administrative districts and 543 Parliamentary Constituencies (PCs) in India.

RESULTS

Nationally, 80.3% of children had dietary failure and 53.7% had at least one anthropometric failure. The prevalence for the four DAF types was: 44.0% (BF), 36.3% (DFO), 9.8% (AFO), and 9.9% (NF). Dietary and anthropometric measures were discordant for 46.1% of children; these children had nutritional needs identified by only one of the two measures. Nationally, this translates to 12 181 627 children with DFO and 3 281 913 children with AFO; the nutritional needs of these children would not be captured if using only dietary or anthropometric assessment. Substantial variation was observed across districts and PCs for all DAF types. The interquartile ranges for districts were largest for BF (29.8%-53.0%) and lowest for AFO (5.5%-13.4%).

CONCLUSIONS

The current emphasis on anthropometry for measuring nutritional need should be complemented with diet- and food-based measures. By differentiating inadequate food intake from other causes of undernutrition, the DAF typology brings precision in identifying nutritional needs among children. These insights may improve the development and targeting of nutrition interventions.

Do tribal children experience elevated risk of poor nutritional status in India? A multilevel analysis

Economic progress in India over the past three decades has not been accompanied by a commensurate improvement in the nutritional status of children, and a disproportionate burden of undernutrition is still focused on socioeconomically disadvantaged populations in the poorest regions. This study examined the nutritional status of children under 3 years of age using data from the fourth round of Indian National Family Health Survey conducted in 2015-2016. Child undernutrition was assessed in a sample of 126,431 under-3 children using the anthropometric indices of stunting, underweight and wasting ('anthropometric failure') across 640 districts, 5489 primary sampling units and 35 states/UTs of India. Descriptive statistics were used to examine the regional pattern of childhood undernutrition. Multilevel logistic regression models were fitted to examine the adjusted effect of social group (tribal vs non-tribal) and economic, demographic and contextual factors on the risks of stunting, underweight and wasting accounting for the hierarchical nature of the data. Interaction effects were estimated to model the joint effects of socioeconomic position (household wealth, maternal education, urban/rural residence and geographical region) and social group (tribal vs non-tribal) with the likelihood of anthropometric failure among children. The burden of childhood undernutrition was found to vary starkly across social, economic, demographic and contextual factors. Interaction effects demonstrated that tribal children from economically poorer households, with less-educated mothers, residing in rural areas and living in the Central region of India had elevated odds of anthropometric deprivation than other tribal children. The one-size-fits-all approach to tackling undernutrition in tribal children may not be efficient and could be counterproductive.

Dietary Variation among Children Meeting and Not Meeting Minimum Dietary Diversity: An Empirical Investigation of Food Group Consumption Patterns among 73,036 Children in India

BACKGROUND

Minimum Dietary Diversity (MDD) is a widely used indicator of adequate dietary micronutrient density for children 6-23 mo old. MDD food-group data remain underutilized, despite their potential for further informing nutrition programs and policies.

OBJECTIVES

We aimed to describe the diets of children meeting MDD and not meeting MDD in India using food group data, nationally and subnationally.

METHODS

Food group data for children 6-23 mo old (n = 73,036) from the 2015-16 National Family Health Survey in India were analyzed. Per WHO standards, children consuming ≥5 of the following food groups in the past day or night met MDD: breast milk; grains, roots, or tubers; legumes or nuts; dairy; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Children not meeting MDD consumed <5 food groups. We analyzed the number and types of foods consumed by children meeting MDD and not meeting MDD at the national and subnational geographic levels.

RESULTS

Nationally, children not meeting MDD most often consumed breast milk (84.5%), grains, roots, and tubers (62.0%), and/or dairy (42.9%). Children meeting MDD most often consumed grains, roots, and tubers (97.6%), vitamin A-rich fruits and vegetables (93.8%), breast milk (84.1%), dairy (82.1%), other fruits and vegetables (79.5%), and/or eggs (56.5%). For children not meeting MDD, district-level dairy consumption varied the most (6.4%-79.9%), whereas flesh foods consumption varied the least (0.0%-43.8%). For children meeting MDD, district-level egg consumption varied the most (0.0%-100.0%), whereas grains, roots, and tubers consumption varied the least (66.8%-100.0%).

CONCLUSIONS

Children not meeting MDD had low fruit, vegetable, and protein-rich food consumption. Many children meeting MDD also had low protein-rich food consumption. Examining the number and types of foods consumed highlights priorities for children experiencing the greatest dietary deprivation, providing valuable complementary information to MDD.

Child Undernutrition and Convergence of Multisectoral Interventions in India: An Econometric Analysis of National Family Health Survey 2015-16

In India and worldwide, there has been increased strategic focus on multisectoral convergence of nutrition-specific and nutrition-sensitive interventions to attain rapid reductions in child undernutrition. For instance, a Convergence Action Plan in India has been formed to synchronize and converge various nutrition-related interventions across ministries of union and state governments under a single umbrella. Given the large variation in number, nature and impact of these interventions, this paper aims to quantify the contribution of each intervention (proxied by relevant covariates) toward reducing child stunting and underweight in India. The interventions are classified under six sectors: (a) health, (b) women and child development, (c) education, (d) water, sanitation, and hygiene, (e) clean energy, and (f) growth sector. We estimate the potential reduction in child stunting and underweight in a counterfactual scenario of “convergence” where all the interventions across all the sectors are simultaneously and successfully implemented. The findings from our econometric analysis suggests that under this counterfactual scenario, a reduction of 18.37% points (95% CI: 16.77; 19.95) in stunting and 20.26% points (95% CI: 19.13; 21.39) in underweight can be potentially achieved. Across all the sectors, women and child development and clean energy were identified as the biggest contributors to the potential reductions in stunting and underweight, underscoring the importance of improving sanitation-related practices and clean cooking fuel. The overall impact of this convergent action was relatively stronger for less developed districts. These findings reiterate a clear role and scope of convergent action in achieving India's national nutritional goals. This warrants a complete outreach of all the interventions from different sectors.

Association of Poor Sanitation With Growth Measurements Among Children in India

Importance

Much research on sanitation and linear growth in low- and middle-income countries focuses on children younger than 5 years. However, poor sanitation may be associated with growth faltering during middle and late childhood to a greater extent than previously recognized.

Objective

To characterize the association of poor sanitation with height-for-age z (HAZ) scores in children and adolescents in India aged 0 to 18 years.

Design, Setting, and Participants

This cross-sectional study examined 134 882 children and adolescents aged 0 to 18 years who were surveyed in the fourth round of India's District Level Household and Facilities Survey (survey conducted August 2012 to February 2014). Data were analyzed from June 1, 2019, to August 20, 2019.

Exposures

Proportion of households reporting open defecation at the village level (to account for its high negative externality) and household-level access to boiled or filtered drinking water.

Main Outcomes and Measures

Individual-level HAZ scores were measured in standard deviations. The association of exposures with outcomes was estimated using ordinary least-squares regression stratified by sex (boys and girls) and 4 age groups (≤1, >1 to ≤7, >7 to ≤12, >12 to ≤18 years). Models controlled for parental height and education, socioeconomic status, maternal age at birth, hemoglobin level, and indicators for state and birth year to adjust for regional (state) and temporal (birth year) fixed effects.

Results

The sample comprised 70 463 male (52.5%) and 64 419 female (47.8%) children and adolescents aged 0 to 18 years; 46 722 participants (34.6%) were aged older than 12 to 18 years. Open defecation was inversely associated with HAZ score among all age groups except boys aged 1 year and younger (>1 to ≤7 years: β, -0.22; 95% CI, -0.35 to -0.10; >7 to ≤12 years: β, -0.15; 95% CI, -0.24 to -0.06; >12 to ≤18 years: β, -0.10; 95% CI, -0.19 to -0.01) and among girls aged between 7 and 18 years (>7 to ≤12 years: β, -0.22; 95% CI, -0.33 to -0.12; >12 to ≤18 years: β, -0.16; 95% CI, -0.23 to -0.09). Boiled or filtered drinking water was positively associated with HAZ score among younger girls (≤1 year: β, 0.26; 95% CI, 0.07 to 0.45; >1 to ≤7 years: β, 0.07; 95% CI, 0.01 to 0.14) and across all age groups in boys (≤1 years: β, 0.19; 95% CI, 0.03 to 0.35; >1 to ≤7 years: β, 0.07; 95% CI, 0.00 to 0.14; >7 to ≤12 years: β, 0.08; 95% CI, 0.03 to 0.13; >12 to ≤18 years: β, 0.06; 95% CI, 0.01 to 0.11).

Conclusions and Relevance

In this study, open defecation and lack of boiled or filtered drinking water were inversely associated with height-for-age measures across all ages in children and adolescents in India. Improved sanitation may benefit growth among children and adolescents older than 5 years.

Factors Associated With Child Stunting, Wasting, and Underweight in 35 Low- and Middle-Income Countries

IMPORTANCE

Evidence on the relative importance of various factors associated with child anthropometric failures (ie, stunting, underweight, and wasting) and their heterogeneity across countries can inform global and national health agendas.

OBJECTIVE

To assess the relative significance of factors associated with child anthropometric failures in 35 low- and middle-income countries (LMICs).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of 299 353 children who were born singleton and aged 12 to 59 months with nonpregnant mothers and valid anthropometric measures assessed the strengths of associations of 26 factors with child stunting, underweight, and wasting, using Demographic and Health Surveys (2007-2018) from 35 LMICs. Data analysis was conducted from July 2019 to February 2020.

EXPOSURES

A total of 9 direct factors (ie, dietary diversity score; breastfeeding initiation; vitamin A supplements; use of iodized salt; infectious disease in past 2 weeks; oral rehydration therapy for children with diarrhea; care seeking for suspected pneumonia; full vaccination; and indoor pollution) and 17 indirect factors (household wealth; maternal and paternal education; maternal and paternal height and body mass index; maternal autonomy for health care, movement, and money; water source; sanitation facility; stool disposal; antenatal care; skilled birth attendant at delivery; family planning needs; and maternal marriage age) were assessed.

MAIN OUTCOMES AND MEASURES

Three anthropometric failure outcomes were constructed based on the 2006 World Health Organization child growth standards: stunting (height-for-age z score less than -2 standard deviations [SDs]), underweight (weight-for-age z score less than -2 SDs), and wasting (weight-for-height z score less than -2 SDs).

RESULTS

Among the 299 353 children aged 12 to 59 months included in the analysis, 38.8% (95% CI, 38.6%-38.9%) had stunting, 27.5% (95% CI, 27.3%-27.6%) had underweight, and 12.9% (95% CI, 12.8%-13.0%) had wasting. In the pooled sample, short maternal height was the strongest factor associated with child stunting (odds ratio [OR], 4.7; 95% CI, 4.5-5.0; P < .001), followed by lack of maternal education (OR, 1.9; 95% CI, 1.8-2.0; P < .001), poorest household wealth (OR, 1.7; 95% CI,1.6-1.8; P < .001), and low maternal body mass index (OR, 1.6; 95% CI, 1.6-1.7; P < .001). Short paternal height was also significantly associated with higher odds of stunting (OR, 1.9; 95% CI, 1.7-2.2; P < .001). Consistent results were found for underweight (eg, short maternal height: OR, 3.5; 95% CI, 3.3-3.7; P < .001; lack of maternal education: OR, 1.8; 95% CI, 1.7-2.0; P < .001) and wasting (eg, low maternal body mass index: OR, 2.3; 95% CI, 2.1-2,4; P < .001; poorest household wealth: OR, 1.2; 95% CI, 1.1-1.3; P < .001). Parental nutritional status and household socioeconomic conditions ranked the strongest (1st to 4th) for most countries, with a few exceptions (eg, lack of maternal education ranked 18th-20th in 8 countries for child wasting). Other factors were not associated with anthropometric failures in pooled analysis and had large country-level heterogeneity; for example, unsafe water was not associated with child underweight in the pooled analysis (OR, 0.97; 95% CI, 0.95-1.00; P < .001), and it ranked from 4th to 20th across countries.

CONCLUSIONS AND RELEVANCE

In this study, socioeconomic conditions and parental nutritional status were the strongest factors associated with child anthropometric failures. Poverty reduction, women's education, and nutrition programs for households could be important strategies for reducing child undernutrition; however, country-specific contexts should be considered in national policy discussions.