Trends in the triple burden of malnutrition
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Despite decades of rapid economic growth, India continues to have the largest share of the world’s undernourished and in recent years, overweight and obesity rates have begun to increase rapidly.

A recent paper in Agricultural Economics investigates these trends and patterns of malnutrition in India. The paper analyses state-level and India-level trends in undernutrition and overweight and obesity rates among women and children. Based on these trends, the paper investigates the dietary transitions occurring in India, highlighting potential associations between dietary quality and malnutrition. The paper covers the period from 1992 to 2014 using data from a variety of sources including National Family Health Surveys (NFHS), District-Level Household and Facility Surveys (DLHS), the Rapid Survey on Children (RSOC), and consumer expenditure surveys conducted by the National Sample Survey Organization (NSSO).

Regarding undernutrition, the study finds that there have been substantial improvements in the level of moderate stunting in most states.  Progress has been uneven, however, as poorer states such as Bihar and Uttar Pradesh have generally experienced lower declines (both from around 65 to 50 percent from 1992 to 2014) than richer states such as Maharashtra and Haryana (from around 55 to 35 percent). However, in recent years rates of reduction have diminished and on average around one-fifth to one-third of young children continue to suffer from severe stunting in most of India’s states. For instance, Kerala and Tamil Nadu had the lowest levels of stunting to begin with, but saw hardly any reduction between 2005–2006 and 2013–2014. The prevalence of women who are moderately underweight has declined in all states from 1992, however, there is evidence of levelling off in recent years.

Over the same period, 1992 to 2014, there has been a significant increase in overnutrition, as measured by the percentage of women with a BMI score over 25. The studies covered show an increase in overweight rates in nearly all states, even though the magnitudes remain below 15 percent in the poorer states. These increases have occurred fairly rapidly, in 1998 only 2 states had overweight prevalence rates exceeding 20 percent but by 2014, that number had risen to 6. Additionally, in some states, such as Tamil Nadu, Kerala, Punjab, Himachal Pradesh, the percentage of women who are overweight is greater than those who are classified as underweight (with a BMI score less than 18.5). The studies covered also illustrate some interesting trends in overnutrition. The trends suggest that overnutrition is associated with higher levels of income but that it is occurring increasingly in rural areas, whereas in the past it was mainly limited to urban areas. The paper also notes that the increases in overweight and obesity rates are not uniform across India;  some states, notably richer ones as well as southern states, are recording much greater increases in obesity.

The paper goes on to investigate how and to what extent these trends can be explained by changes in diet and diet quality. The studies show that there is not, contrary to some expectations, a strong relationship between per capita calorie consumption and indicators of undernutrition. During the time period covered in the study, per capita calorie consumption in India fell (despite an increase in some states) while stunting and undernutrition rates all decreased, suggesting that calorie consumption alone is not a good indicator of undernutrition. A more in-depth analysis shows that dietary changes and increasing diet diversity is likely to have contributed to these decreases in undernutrition. The study shows that there is a negative relationship between the share of calories obtained from fruits, vegetables and pulses and the two measures of undernutrition (the prevalence of underweight women and stunting among children). Both measures decline significantly with this measure of diet quality. These negative associations also hold when the diet quality measure is the share of energy derived from dairy, meat, eggs, and fish but the correlation is much lower. This finding is significant; however, the study does highlight that the extent of diet diversification is low and is changing slowly and that this may explain the relatively low reductions in undernutrition experienced in India since 1992. The poorest are generally found to have the least diversified diets, depending heavily on cereals, while the richest have the most diversified diets.

Regarding overnutrition, the study finds a positive correlation between the share of energy derived from oils and sugars and measures of overnutrition. It appears that indicators of overnutrition are responsive to worsening diet quality (increased shares of oils, fats and cereals). There are also positive relationships between measures of overnutrition and the other measures of diet quality including the increased consumption of meat, egg, fish, pulses, fruits, and vegetables. The paper suggests that this can be explained by an income effect that underlies both variables: richer districts have both greater levels of obesity and better diet quality.

In conclusion, the paper highlights that rather than the quantity of food, it is the quality of diet that seems to be strongly correlated to malnutrition in India. Based on the findings, the paper highlights a number of broad implications. Namely, that more research and policy interventions need to be directed at understanding and tackling overnutrition. Second, the paper highlights that these findings, especially those related to undernutrition, need to be interpreted in light of food price policy, which continues to be predominantly focused on cereals. Food inflation, since the early 1990s has been driven increasingly by non-cereals which has likely hindered larger improvements in diet quality, especially for the poor. This suggests that price interventions for other products, namely fruits and vegetables, could increase their consumption, thus decreasing rates of undernutrition. Lastly, the paper highlights the need for more nuanced public health interventions that are focused on both under and over nutrition.

By: Bas Paris





Photo credit:Flickr, HarvestPlus