National-­‐Level  Trends  in  Outcomes,  Determinants  and  Interventions  

Rasmi  Avulawith  Purnima  Menon,  Sneha  Mani,  Neha  Kohli,  Phuong  Nguyen  

International  Food  Policy  Research  Institute

New  Delhi|  May  3,  2017

Nutrition  in  the  global  agenda

2.2 BY  2030  END  ALL  FORMS  OF  MALNUTRITION,  INCLUDING  ACHIEVING  BY  2025  THE  INTERNATIONALLY  AGREED  TARGETS  ON  STUNTING  AND  WASTING  IN  CHILDREN  UNDER  FIVE  YEARS  OF  AGE,  AND  ADDRESS  THE  NUTRITIONAL  NEEDS  OF  ADOLESCENT  GIRLS,  PREGNANT  AND  LACTATING  WOMEN,  AND  OLDER  PERSONS

Tracking  progress:    Health  and  nutrition  surveys  in  India,  1990-­‐2015*

1990 1995 2000 2005 2010 2015

NFHS-­‐1 NFHS-­‐2 NFHS-­‐3 NFHS-­‐4

DLHS-­‐1 DLHS-­‐2 DLHS-­‐3

AHS AHS AHSRSOCSu

rvey  ty

pes                  

CNNS

*only  includes  surveys  representative  at  the  district  level  or  higherNFHS:    National  Family  Health  Survey;  DLHS:    District  Level  Household  SurveyAHS:    Annual  Health  Survey;  RSOC:    Rapid  Survey  on  ChildrenCNNS:    Comprehensive  National  Nutrition  Survey

POSHAN  Report:  Trends  in  nutrition  outcomes,  determinants,  and  interventions• Description  of  national  and  state  trends  – WHA  targets– Multiple  determinants

– Nutrition-­‐specific  interventions

• Generate  a  dialogue  to  support  policy  decisions  for  improving  nutrition  in  multiple  states  

Methods• Data  sources:– National  Family  Health  Survey-­‐4  (NFHS-­‐4,  2015–16)  factsheets  

– National  Family  Health  Survey-­‐3  (2005–06)  factsheets/report

– Rapid  Survey  on  Children  (RSoC,  2013–2014)  for  indicators  that  are  currently  not  available  in  NFHS-­‐4  fact  sheets.

• Analysis  – trends  and  levels– Outcome  indicators– Immediate  and  underlying  determinants  – Coverage  of  nutrition-­‐specific  interventions

Indicators  based  on  UNICEF’s  conceptual  framework  and  Indian  policy  frameworkOutcomes  (WHA  targets+)• Stunting• Wasting• Low  birthweight• Exclusive  breastfeeding  • Underweight• Anemia  (women  of  reproductive  age,  

pregnant  women,  children)Immediate  determinants• Low  body  mass  index  (BMI)• Early  initiation  of  breastfeeding• Timely  introduction  of  foods• Adequate  diet  • Prevalence  of  acute  respiratory  infection  

(ARI)• Prevalence  of  diarrheaUnderlying  determinants• Women  who  are  literate  • Women  with  at  least  10  years  of  education• Access  to  electricity• Married  before  18• Improved  sanitation  • Improved  drinking  water

Nutrition  interventions• Early  initiation  of  breastfeeding• Timely  introduction  of  foods• Adequate  diet  • Prevalence  of  acute  respiratory  infection  (ARI)• Prevalence  of  diarrhea• ANC  (first  trimester)• ANC  4  or  more  visits)  • ANC-­‐neonatal  tetanus  injections• Consumption  of  IFA  supplements  • Food  supplementation  (pregnancy)• Janani  Suraksha  Yojana (JSY)• Skilled  attendant  at  birth  • Delivery  in  a  health  facility• Birth  registration• Food  supplementation  (lactation)• Full  immunization• Vitamin  A  supplementation

Menon  et  al.  2017.  Trends  in  Nutrition    Outcomes,  Determinants,  and  Interventions  in  India.  Page  15

Trends  in  key  global  nutrition  targets  and  nutrition  outcomes  in  India,  2005-­‐06  to  2015-­‐16

48

19.8

55

46.4

21.5

42.5

59

69.4

38.4

21

53 54.9

18.6

37.5

50

58.4

0

10

20

30

40

50

60

70

Stunting Wasting Anemia  among  women

Exclusive  breastfeeding

Low  birthweight

Underweight   Anemia  among  pregnant  women  

Anemia  among  children  

2005-­‐06 2015-­‐16

32.8

5

61.1

13.7

Source:    NFHS-­‐3;  NFHS-­‐4  and  RSOC  for  low  birth  weightWorld  Health  Assembly  Nutrition  Target  Level

27.9

Stunting  declined  – broad  improvements,  tremendous  state-­‐level  variability  in  extent  of  improvement

2005-­‐06

Source:    NFHS-­‐3;  NFHS-­‐4

2015-­‐16

Changes  in  immediate  determinants  of  nutrition:  Limited progress  on  IYCF  and  child  health

35.5

22.923.4

41.6

52.6

42.7

9 9.2

5.8

2.7

0

10

20

30

40

50

60

70

2006 2016

%

Women  with  body  mass  index  <18.5

Early  initiation  of  breastfeeding

Timely  introduction  of  foods

Diarrhea  in  the  last  two  weeks

ARI  in  the  last  two  weeks

Uttar  PradeshUttarakhand

RajasthanNCT  of  Delhi

PunjabJharkhandChandigarh

Madhya  PradeshBihar

TelanganaAndhra  Pradesh_New

Himachal  PradeshIndia

Andaman  &  Nicobar  IslandHaryanaTripura

Jammu  &  KashmirChattisgarhWest  Bengal

Dadra  and  nagar  haveliGujarat

NagalandLakshadweepTamil  Nadu

Daman  &  DiuKarnataka

MaharashtraArunachal  Pradesh

MeghalayaKeralaAssam

PuducherryManipurSikkimOdisha

MizoramGoa

Andhra  Pradesh

0 20 40 60 80 100%

2006 2016

TripuraRajasthan

BiharUttar  Pradesh

HaryanaMadhya  Pradesh

PunjabIndia

MaharashtraNCT  of  Delhi

Andaman  &  Nicobar  IslandKarnataka

UttarakhandJharkhand

GujaratAssam

Jammu  &  KashmirWest  Bengal

Himachal  PradeshArunachal  Pradesh

ChattisgarhOdisha

Andhra  Pradesh_NewTelangana

SikkimKerala

MeghalayaTamil  NaduMizoramNagaland

PuducherryManipur

Andhra  PradeshChandigarh

Dadra  and  nagar  haveliDaman  &  Diu

GoaLakshadweep

0 20 40 60 80 100%

2006 2016

Early  initiation  of  breastfeeding Timely  introduction  of  complementary  foods

Coverage  of  all nutrition-­‐specific  interventions  increased;  variable  coverage

0

10

20

30

40

50

60

70

80

90

100

2006 2016

%

ANC  visit  during  first  trimester

4+  ANC  visits  for  last  birth

Consumed  IFA  during  pregnancyFood  supplementation  during  pregnancy  Delivery  in  health  facility

Births  assisted  by  a  health  professional  Birth  registration

Food  supplementation  during  lactation  Fully  immunization

Received  vitamin  A    in  the  last  6  monthsFood  supplementation  for  children  ORS  during  diarrhea

0

10

20

30

40

50

60

70

80

90

100

%Coverage  of  interventions  varies  across  continuum  of  care,  among  states  in  2016

Sources:  NFHS-­4.  RSoC data  was  used  for  indicators  on  pregnancy  registration,  food  supplementation  during  pregnancy,  lactating  and  for  children,  visits  by  health  worker,  pediatric  IFA  and  deworming  for  children.  

Women’s  education,  age  at  marriage  and  infrastructure  improved;  sanitation  improved  but  still  remains  a  big  challenge

0

10

20

30

40

50

60

70

80

90

100

2006 2016

%

Women  who  are  literate

Women  with  ≥10  years  education

Girls  married  before  age  of  18

Households  with  access  to  improved  drinking  water

Households  with  access  to  improved  sanitation  facilityHouseholds  with  electricity

Emerging  health  problems:  Non-­‐communicable  diseases

13.4

18.6

7.98.8

20.7

5.8

0

10

20

30

40

50

60

70

Hig  blood  pressure Overweight/Obesity High  sugar  level

%

Men Women

Summary• Progress  on  several  maternal  and  child  nutrition  outcomes in  the  last  decade– Anemia  still  a  public  health  concern  in  India– Stunting  still  a  public  health  concern  in  some  states

• Modest  and  mixed  improvements  in  the  immediate  determinants of  nutrition– Disease  burden  unchanged  

• Intervention  coverage  shows  positive  trends  over  time  for  most  interventions

• Substantial  progress  on  underlying  determinants  – Sanitation  lags  behind

• Interstate  variability  is  masked  in  national  averages– Unpack,  investigate,  set  goals,  develop  strategies