evidence-based blog of Filippo Dibari

Posts Tagged ‘India’

Designing programs to improve diets for maternal and child health: estimating costs and potential dietary impacts of nutrition-sensitive programs in Ethiopia, Nigeria, and India

In Under-nutrition on July 10, 2018 at 6:21 am

from: Health Policy and Planning, Volume 33, Issue 4, 1 May 2018, Pages 564–573

William A Masters Katherine L Rosettie Sarah Kranz Goodarz Danaei Patrick Webb Dariush Mozaffarianthe Global Nutrition and Policy Consortium.

(download here)


Improving maternal and child nutrition in resource-poor settings requires effective use of limited resources, but priority-setting is constrained by limited information about program costs and impacts, especially for interventions designed to improve diet quality.

This study utilized a mixed methods approach to identify, describe and estimate the potential costs and impacts on child dietary intake of 12 nutrition-sensitive programs in Ethiopia, Nigeria and India.

These potential interventions included conditional livestock and cash transfers, media and education, complementary food processing and sales, household production and food pricing programs. Components and costs of each program were identified through a novel participatory process of expert regional consultation followed by validation and calibration from literature searches and comparison with actual budgets. Impacts on child diets were determined by estimating of the magnitude of economic mechanisms for dietary change, comprehensive reviews of evaluations and effectiveness for similar programs, and demographic data on each country.

Across the 12 programs, total cost per child reached (net present value, purchasing power parity adjusted) ranged very widely: from 0.58 to 2650 USD/year among five programs in Ethiopia; 2.62 to 1919 USD/year among four programs in Nigeria; and 27 to 586 USD/year among three programs in India.

When impacts were assessed, the largest dietary improvements were for iron and zinc intakes from a complementary food production program in Ethiopia (increases of 17.7 mg iron/child/day and 7.4 mg zinc/child/day), vitamin A intake from a household animal and horticulture production program in Nigeria (335 RAE/child/day), and animal protein intake from a complementary food processing program in Nigeria (20.0 g/child/day).

These results add substantial value to the limited literature on the costs and dietary impacts of nutrition-sensitive interventions targeting children in resource-limited settings, informing policy discussions and serving as critical inputs to future cost-effectiveness analyses focusing on disease outcomes.

Key message

Existing evidence on cost-effectiveness for nutrition improvement focuses on interventions to address specific diseases. We provide a novel participatory approach to assembling cost and impact data for 12 nutrition-sensitive interventions to improve diet quality in three countries: Ethiopia, Nigeria and India. Programs designed by stakeholders often use resource transfers to influence diets despite their high cost; programs altering food access have lower cost. Future work using these data will analyse net cost-effectiveness.

Reaching the missing middle: Overcoming hunger and malnutrition in middle income countries

In Over-nutrition, Under-nutrition on April 23, 2015 at 7:00 am

by Shenggen Fan and Ertharin Cousin

wfp logo

from WFP web site

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Hunger and malnutrition are not problems exclusive to low income countries.

That is why the international community cannot realise its ambitious international agenda of achieving zero hunger and malnutrition without a renewed focus on countries in economic transition where hunger and malnutrition remain.

The majority of the world’s hungry and malnourished population now live in Middle Income Countries (MICs).

For these countries to best fulfil their vital role in supporting zero hunger and malnutrition, they must promote effective country-led strategies that will reduce hunger and malnutrition at home.

The nutritional value of toilets: How much international variation in child height can sanitation explain?

In Under-nutrition on May 4, 2014 at 7:39 am

by Dean Spears (World Bank). From the Rice Web Site – June 2013

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Physical height is an important economic variable reflecting health and human capital. Puzzlingly, however, differences in average height across developing countries are not well explained by differences in wealth. In particular, children in India are shorter, on average, than children in Africa who are poorer, on average, a paradox called \the Asian enigma” which has received much attention from economists.

 Could toilets help children grow tall, while disease externalities from poor sanitation keep children from reaching their height potentials? This paper provides the first identification of a quantitatively important gradient between child height and sanitation, which can statistically explain a large fraction of international height differences.

I apply three complementary empirical strategies to identify the association between sanitation and child height: country-level regressions across 140 country-years in 65 developing countries; within-country analysis of differences over time within Indian districts; and econometric decomposition of the India-Africa height difference in child level data.

 The effect of sanitation on human capital is quantitatively robustly estimated across these strategies, and does not merely reflect wealth or other dimensions of development. Open defecation, which is exceptionally widespread in India, can account for much or all of the excess stunting in India.

Open Defecation and Childhood Stunting in India: An Ecological Analysis of New Data from 112 Districts

In Under-nutrition on October 5, 2013 at 1:12 pm

Spears D, Ghosh A, Cumming O (2013) Open Defecation and Childhood Stunting in India: An Ecological Analysis of New Data from 112 Districts. PLoS ONE 8(9): e73784

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Poor sanitation remains a major public health concern linked to several important health outcomes; emerging evidence indicates a link to childhood stunting. In India over half of the population defecates in the open; the prevalence of stunting remains very high. Recently published data on levels of stunting in 112 districts of India provide an opportunity to explore the relationship between levels of open defecation and stunting within this population. We conducted an ecological regression analysis to assess the association between the prevalence of open defecation and stunting after adjustment for potential confounding factors. Data from the 2011 HUNGaMA survey was used for the outcome of interest, stunting; data from the 2011 Indian Census for the same districts was used for the exposure of interest, open defecation. After adjustment for various potential confounding factors – including socio-economic status, maternal education and calorie availability – a 10 percent increase in open defecation was associated with a 0.7 percentage point increase in both stunting and severe stunting. Differences in open defecation can statistically account for 35 to 55 percent of the average difference in stunting between districts identified as low-performing and high-performing in the HUNGaMA data. In addition, using a Monte Carlo simulation, we explored the effect on statistical power of the common practice of dichotomizing continuous height data into binary stunting indicators. Our simulation showed that dichotomization of height sacrifices statistical power, suggesting that our estimate of the association between open defecation and stunting may be a lower bound. Whilst our analysis is ecological and therefore vulnerable to residual confounding, these findings use the most recently collected large-scale data from India to add to a growing body of suggestive evidence for an effect of poor sanitation on human growth. New intervention studies, currently underway, may shed more light on this important issue.

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World largest child nutrition program: all is not well?

In Under-nutrition on February 24, 2013 at 7:41 am

by Mukta Singhvi, Sarvjeet Kaur, and Suman Kumari


click here for to download this paper

A country truly concerned about its development would put its children’s health on a higher priority than the GDP. For, population of over a billion can add strength to a country, only, if it is healthy and productive.

In India about 42% of the children are under weight. It has been reported by that on in every three most malnourished children of the world live in India. It is cause worry because such a populace can become a liability in the coming years. The problem of malnutrition is a matter of shame. Despite impressive growth in our GDP, the level of under nutrition in the country is unacceptably high . India has not succeeded in reducing malnutrition fast enough, though the integrated child development services (ICDS) programme continues to be our most important tool to fight malnutrition.

The global community has designated halving the prevalence of under weigh children by 2015 as a key indicator of progress towards the millennium development goal (MDG) of eradicating extreme poverty and hunger. However, it appears that that economic growth alone, though impressive, will not reduce malnutrition sufficiently to meet the MDG. Nutrition target. India’s main early child development and nutrition intervention , the ICDS program has expanded steadily across the country during the last more than three and half decade of its existence. It is one of the World’s largest, most unique well designed and well placed programme to address many of the underlying cause of under nutrition in India. However, it faces a range of implementation difficulties that prevent it from fully realizing its potential.

This article is an attempt to critically examine the World largest programme and identifies the most important weakness in the implementation of ICDS and suggest a way out that can be taken to improve the impact of the programme.

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Public Nutrition in poor settings: the latest publications in peer-reviewed journals

In Under-nutrition on August 28, 2012 at 4:43 pm

This week is particularly full of interesting papers about nutrition-related topics relevant for low-income countries. I could not decide the criteria to make a selection. Therefore I list them all here beneath. Enjoy the reading.

Evaluation of the Rural Primary Health Care project on undernutrition equity among children in rural Western China.
L Pei, D Wang, L Ren, and H Yan
Health Policy Plan. 2012. 

The importance of maternal undernutrition for maternal, neonatal, and child health outcomes: an editorial. [Editorial].
JB Mason, LS Saldanha, and R Martorell
Food Nutr Bull. 2012; 33: S3.

Policies and program implementation experience to improve maternal nutrition in Ethiopia.
LS Saldanha, L Buback, JM White, A Mulugeta, SG Mariam, AC Roba, H Abebe, and JB Mason
Food Nutr Bull. 2012; 33: S27. 

Opportunities for improving maternal nutrition and birth outcomes: synthesis of country experiences.
JB Mason, LS Saldanha, U Ramakrishnan, A Lowe, EA Noznesky, AW Girard, DA McFarland, and R Martorell
Food Nutr Bull. 2012; 33: S104. 

A situation analysis of public health interventions, barriers, and opportunities for improving maternal nutrition in Bihar, India.
EA Noznesky, U Ramakrishnan, and R Martorell
Food Nutr Bull. 2012; 33: S93. 

Public health interventions, barriers, and opportunities for improving maternal nutrition in India.
U Ramakrishnan, A Lowe, S Vir, S Kumar, R Mohanraj, A Chaturvedi, EA Noznesky, R Martorell, and JB Mason
Food Nutr Bull. 2012; 33: S71. 

Public health interventions, barriers, and opportunities for improving maternal nutrition in Northeast Nigeria.
AW Girard, C Dzingina, O Akogun, JB Mason, and DA McFarland
Food Nutr Bull. 2012; 33: S51. [MEDLINE Citation]

and also:

Determinants of Cognitive Development of Low SES Children in Chile: A Post-transitional Country with Rising Childhood Obesity Rates.
M Galvan, R Uauy, C Corvalan, G Lopez-Rodriguez, and J Kain
Matern Child Health J, Aug 2012

Maternal Multiple Micronutrient Supplements and Child Cognition: A Randomized Trial in Indonesia
Elizabeth L. Prado, Katherine J. Alcock, Husni Muadz, Michael T. Ullman, Anuraj H. Shankar for the SUMMIT Study Group
Pediatrics, Aug 2012; 10.1542/peds.2012-0412.

Growth and complementary feeding in the Americas.
CK Lutter
Nutr Metab Cardiovasc Dis, Aug 2012

Intergenerational effects of maternal birth season on offspring size in rural Gambia
Ian J. Rickard, Alexandre Courtiol, Andrew M. Prentice, Anthony J. C. Fulford, Tim H. Clutton-Brock, and Virpi Lummaa
Proc R Soc B, Aug 2012; 10.1098/rspb.2012.1363.

Worldwide implementation of the WHO Child Growth Standards 

Mercedes de Onisa1 c1, Adelheid Onyangoa1, Elaine Borghia1, Amani Siyama1, Monika Blössnera1 and Chessa Luttera2 for the WHO Multicentre Growth Reference Study Group

Public Health Nutrition / Volume 15 / Issue 09 / September 2012 , pp 1603-1610

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Video – The Republic Of Hunger: every third malnourished child in the world is from India

In Under-nutrition on August 16, 2012 at 6:53 am

From AlJazeera web site:

“More than 40 per cent of India’s 61 million children are malnourished, prompting the prime minister to declare the problem a “national shame”.

“A recent report reveals that levels are twice that of sub-Saharan Africa, making every third malnourished child in the world an Indian.

“India has one of the fastest-growing economies in the world and runs one of the largest child feeding programmes.

“But critics say only a fraction of aid reaches the needy.”


Find more posts about India and malnutrition on this blog.

Slums and Malnourishment: Evidence From Women in India

In Under-nutrition on June 3, 2012 at 8:25 am

by H Swaminathan and A Mukherji

Am J Public Health, May 17, 2012


Objectives. We examined the association between slum residence and nutritional status in women in India by using competing classifications of slum type.

Methods. We used nationally representative data from the 2005-2006 National Family Health Survey (NFHS-3) to create our citywide analysis sample. The data provided us with individual, household, and community information. We used the body mass index data to identify nutritional status, whereas the residential status variable provided slum details. We used a multinomial regression framework to model the 3 nutrition states-undernutrition, normal, and overnutrition.

Results. After we controlled for a range of attributes, we found that living in a census slum did not affect nutritional status. By contrast, living in NFHS slums decreased the odds of being overweight by 14% (95% confidence interval [CI]?=?0.79, 0.95) and increased the odds of being underweight by 10% (95% CI?=?1.00, 1.22).

Conclusions. The association between slum residence and nutritional outcomes is nuanced and depends on how one defines a slum. This suggests that interventions targeted at slums should look beyond official definitions and include current living conditions to effectively reach the most vulnerable.

Agriculture and malnutrition in India

In Under-nutrition on June 3, 2012 at 8:19 am

A Gulati, A Ganesh-Kumar, G Shreedhar, and T Nandakumar

Food Nutr Bull, March 1, 2012; 33(1): 74-86.



BACKGROUND: Despite the high and relatively stable overall growth of the economy, India’s agriculture sector is underperforming and a vast section of the population remains undernourished.

OBJECTIVE: To explore the possible interplay between agricultural performance and malnutrition indicators to see whether states that perform better in agriculture record better nutritional outcomes.

METHODS: Correlation analysis and a simple linear regression model were used to study the relationship between agricultural performance and malnutrition among children under 5 years of age and adults from 15 to 49 years of age at 20 major states using data from the National Family Health Survey-3 for the year 2005/06 and the national accounts.

RESULTS: Indicators of the level of agricultural performance or income have a strong and significant negative relationship with indices of undernutrition among adults and children, a result suggesting that improvement of agricultural productivity can be a powerful tool to reduce undernutrition across the vast majority of the population. In addition to agriculture, access to sanitation facilities and women’s literacy were also found to be strong factors affecting malnutrition. Access to healthcare for women and child-care practices, in particular breastfeeding within 1 hour after birth, are other important determinants of malnutrition among adults and children.

CONCLUSIONS: Malnutrition is a multidimensional problem that requires multisectoral interventions. The findings show that improving agricultural performance can have a positive impact on nutritional outcomes. However, improvements in agriculture alone cannot be effective in combating malnutrition if several other mediating factors are not in place. Interventions to improve education, health, sanitation and household infrastructure, and care and feeding practices are critical. Innovative strategies that integrate agriculture and nutrition programs stand a better chance of combating the malnutrition problem.

The effect of a vaccination program on child anthropometry: evidence from India’s Universal Immunization Program.

In Under-nutrition on June 3, 2012 at 8:08 am

by TD Anekwe and S Kumar

J Public Health, May 18, 2012

BACKGROUND: Childhood vaccination may protect children’s nutritional status and lead to improved child growth in developing countries. This study evaluates the effect of India’s childhood vaccination program Universal Immunization Program (UIP) on the growth of children under 4 years of age.

METHODS: Regression models were estimated to examine the effect of UIP on vaccination status and children’s anthropometric outcomes. Regression models were also estimated to test whether UIP’s effect was uniform across various subpopulations of Indian children.

RESULTS: UIP increased height-for-age among Indian children who were <4 years of age in 1992-1993, resulting in a 17-22% reduction in the height-for-age-deficit of the average child. The program appears to have had no effect on other anthropometric indicators or vaccination status. UIP also led to differential changes in anthropometry and vaccination status, based on differences in maternal education and scheduled-caste status.

CONCLUSIONS: UIP led to improved child growth. This suggests that vaccination programs-in addition to being a major intervention for reducing child mortality-might be considered a tool for mitigating undernutrition in developing countries. This study also adds to the growing evidence that childhood vaccination programs are high-return investments because they produce long-term health benefits for children.

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