The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017

This article assesses the overall burden of child and maternal malnutrition in every state of India from 1990 through 2017.

Summary

Background

Malnutrition is a major contributor to disease burden in India. To inform subnational action, we aimed to assess the disease burden due to malnutrition and the trends in its indicators in every state of India in relation to Indian and global nutrition targets.

Methods

We analysed the disease burden attributable to child and maternal malnutrition, and the trends in the malnutrition indicators from 1990 to 2017 in every state of India using all accessible data from multiple sources, as part of Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three groups using their Socio-demographic Index (SDI) calculated by GBD on the basis of per capita income, mean education, and fertility rate in women younger than 25 years. We projected the prevalence of malnutrition indicators for the states of India up to 2030 on the basis of the 1990–2017 trends for comparison with India National Nutrition Mission (NNM) 2022 and WHO and UNICEF 2030 targets.

Findings

Malnutrition was the predominant risk factor for death in children younger than 5 years of age in every state of India in 2017, accounting for 68·2% (95% UI 65·8–70·7) of the total under-5 deaths, and the leading risk factor for health loss for all ages, responsible for 17·3% (16·3–18·2) of the total disability-adjusted life years (DALYs). The malnutrition DALY rate was much higher in the low SDI than in the middle SDI and high SDI state groups. This rate varied 6·8 times between the states in 2017, and was highest in the states of Uttar Pradesh, Bihar, Assam, and Rajasthan. The prevalence of low birthweight in India in 2017 was 21·4% (20·8–21·9), child stunting 39·3% (38·7–40·1), child wasting 15·7% (15·6–15·9), child underweight 32·7% (32·3–33·1), anaemia in children 59·7% (56·2–63·8), anaemia in women 15–49 years of age 54·4% (53·7–55·2), exclusive breastfeeding 53·3% (51·5–54·9), and child overweight 11·5% (8·5–14·9). If the trends estimated up to 2017 for the indicators in the NNM 2022 continue in India, there would be 8·9% excess prevalence for low birthweight, 9·6% for stunting, 4·8% for underweight, 11·7% for anaemia in children, and 13·8% for anaemia in women relative to the 2022 targets. For the additional indicators in the WHO and UNICEF 2030 targets, the trends up to 2017 would lead to 10·4% excess prevalence for wasting, 14·5% excess prevalence for overweight, and 10·7% less exclusive breastfeeding in 2030. The prevalence of malnutrition indicators, their rates of improvement, and the gaps between projected prevalence and targets vary substantially between the states.

Interpretation

Malnutrition continues to be the leading risk factor for disease burden in India. It is encouraging that India has set ambitious targets to reduce malnutrition through NNM. The trends up to 2017 indicate that substantially higher rates of improvement will be needed for all malnutrition indicators in most states to achieve the Indian 2022 and the global 2030 targets. The state-specific findings in this report indicate the effort needed in each state, which will be useful in tracking and motivating further progress. Similar subnational analyses might be useful for other low-income and middle-income countries.

Funding

Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Introduction

Malnutrition is a major contributor to disease burden, with more than half of global deaths in children younger than 5 years of age attributable to undernutrition, the vast majority of which are in low-income and middle-income countries, including India.

However, overweight among children is also increasing globally, including in Africa and Asia.

Addressing the challenge of malnutrition in children and women is essential to ensure optimal cognitive growth and development and overall health and productivity.

Addressing the global burden of malnutrition is a major priority.

To spur action and monitor progress, WHO Global Nutrition Targets were established for six malnutrition indicators to be achieved by 2025.

The UN Sustainable Development Goals (SDGs) also set targets with the aim of eliminating malnutrition by 2030.

To strengthen the joint efforts towards reducing malnutrition worldwide, 2016–25 was declared, by the UN, as the Decade of Action on Nutrition.

A WHO and UNICEF review in 2018 suggested that the SDG goal of eliminating all forms of malnutrition by 2030 was aspirational but not achievable and, on the basis of trends so far, recommended targets for the malnutrition indicators up to 2030.

Research in context

Evidence before this study

Existing evidence suggests that India, with a population of 1·4 billion people residing across states at varying levels of health transition, has a large and persistent burden of malnutrition, especially among children and women of reproductive age. We searched PubMed for published literature on malnutrition in India, Google for reports in the public domain, and references in these papers and reports, using the search terms “anaemia”, “breastfeeding”, “burden”, “child growth failure”, “child obesity”, “child overweight”, “DALY”, “death”, “epidemiology”, “global nutrition targets”, “India”, “infant”, “low birthweight”, “malnutrition”, “morbidity”, “mortality”, “national nutrition mission”, “neonate”, “prevalence”, “stunting”, “sustainable development goals”, “under-five”, “undernutrition”, “underweight”, and “wasting” on April 4, 2019, without language or publication date restrictions. We found several previous studies that have estimated subnational variations in malnutrition burden in India and its association with health outcomes, mainly using single data sources. However, a comprehensive understanding of the variations between the states of India in the prevalence of each malnutrition indicator, the associated deaths and disease burden, and its progress towards achieving the Indian and the global nutrition targets, using all available data sources in a single framework has not been compiled to inform relevant policy interventions suitable for the situation in each state.

Added value of this study

This study provides a comprehensive account of the burden of child and maternal malnutrition in every state of India from 1990 to 2017, by use of all available and accessible data that were analysed in the unified Global Burden of Diseases, Injuries, and Risk Factors Study framework. The findings highlight that, even with the many efforts to reduce malnutrition in India, it remains the predominant risk factor for deaths and disease burden in children younger than 5 years and the leading risk factor for disease burden in all ages combined. This study compares the projected prevalence of the malnutrition indicators in each state based on the trends up to 2017, with the targets set by the India National Nutrition Mission for 2022 and WHO and UNICEF for 2030. The substantial gaps between the trends and targets estimated in this report for most states of India indicate that progress toward all malnutrition indicators needs to be accelerated. These gaps vary between the states, indicating the extent of additional effort needed to control malnutrition in each state. The findings highlight that the modest rate of improvement in low birthweight, which is the biggest contributor among the malnutrition indicators to deaths and disease burden in children younger than 5 years of age, should be addressed through focused policy action. Besides the substantial continuing burden of poor nutrition in India, this study also reports that child overweight is increasing rapidly across all states of India.

Implications of all available evidence

Malnutrition remains one of the most serious public health challenges across India, although substantial heterogeneity exists between the states for the various malnutrition indicators and their trends over time. The resurgence in policy interest in India to reduce malnutrition across the country through the National Nutrition Mission is encouraging. This momentum can benefit from the use of state-level trends in this study, which highlight the extent of effort needed in each state to achieve the national and the global targets for the various malnutrition indicators.

Decades of policy and programmatic efforts have been made in India to tackle the continuing challenge of malnutrition. In 2017, India released the National Nutrition Strategy, which outlined measures to address malnutrition across the life cycle.

In early 2018, the Prime Minister of India launched the National Nutrition Mission (NNM), also known as POSHAN Abhiyaan, to bring focus and momentum to this effort, which has the overarching goal of reducing child and maternal malnutrition.

India had a population of 1·38 billion in 2017, spread across 29 states and seven union territories, which are at varying levels of development, leading to a heterogeneous distribution of health risks and their effects.

The India State-Level Disease Burden Initiative has reported a varied epidemiological transition across the states of India since 1990 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD).

Some subnational studies in India have reported the trends in one or more malnutrition indicators, and some from other countries have reported trends in malnutrition burden or trends in child growth failure indicators.

However, there has been no comprehensive consolidation of the malnutrition burden and the trends in all major malnutrition indicators in all states of any country using all available data sources that also relates the projected subnational trends with the policy targets for 2022 and 2030. In this report, we present consolidated findings for each state in India from 1990 to 2017 and compare these trends with Indian and global targets up to 2030 to inform state-specific policy action.

Methods

Overview

The analysis and findings of child and maternal malnutrition reported in this Article were produced by the India State-Level Disease Burden Initiative as part of GBD 2017. The work of this Initiative has been approved by the Health Ministry Screening Committee at the Indian Council of Medical Research and the ethics committee of the Public Health Foundation of India. A comprehensive description of the metrics, data sources, and statistical modelling for GBD 2017 has been reported elsewhere.

The GBD 2017 methods relevant for this paper are summarised here and described in detail in the appendix (pp 3–26).

Estimation of exposure to malnutrition

The GBD comparative risk assessment framework was used to estimate malnutrition exposure and attributable disease burden. The components of child and maternal malnutrition in GBD are described in the appendix (p 5). All accessible data sources from India were used, including national household surveys, a variety of dietary and nutrition surveys, and other epidemiological studies (appendix pp 25–37). The modelling approaches integrated multiple data inputs, using Spatiotemporal Gaussian process regression, and borrowed information across age, time, and location to produce the best possible estimates of risk exposure by location, age, sex, and year.

For the purpose of reporting the prevalence of the eight malnutrition indicators included in the India NNM target 2022 and the WHO and UNICEF target 2030, the following definitions were used: low birthweight as less than 2500 g; stunting, wasting, and underweight in children younger than 5 years as height-for-age, weight-for-height, and weight-for-age below two SDs of the median in the WHO 2006 standard curve; anaemia in children younger than 5 years as haemoglobin less than 110 g/L; anaemia in women 15–49 years of age as haemoglobin less than 110 g/L if pregnant and 120 g/L if not pregnant; exclusive breastfeeding as no oral food or fluid intake during the first 6 months of life except breast milk and oral rehydration solution drops or syrups containing vitamins, minerals or medicines; and overweight in children aged 2–4 years as body-mass index above the monthly cutoff for normal weight as reported in the International Obesity Task Force tables.

Estimation of deaths and DALYs attributable to malnutrition

Estimation of attributable disease burden included ascertainment of relative risk of disease outcomes for risk exposure-disease outcome pairs with sufficient evidence of a causal relationship in randomised controlled trials, prospective cohort studies, or case-control studies, as assessed with an approach similar to the World Cancer Research Fund grading system.

Population attributable fractions were estimated from risk exposure, relative risks of outcomes due to exposures, and the theoretical minimum risk exposure (lowest level of risk exposure, below which its relation with a disease outcome is not supported by available evidence) for each malnutrition indicator as explained in the appendix (pp 3–24). Population attributable fractions were used to produce estimates of deaths and disability-adjusted life-years (DALYs) attributable to each malnutrition risk factor by location, age, sex, and year. DALYs are the summary measure of years of healthy life lost due to disability (YLDs) and years of life lost due to premature mortality (YLLs). The major data inputs included vital registration, verbal autopsy studies, large population-level surveys, surveillance data, and hospital-based and community-based studies (appendix pp 25–37).GBD uses covariates, which are explanatory variables that have a known association with the outcome of interest, to arrive at the best possible estimate when data for the outcome are scarce but data for covariates are available.

This approach was part of the estimation process for the findings reported.

Analysis presented in this paper

We report findings for 31 geographical units in India: 29 states, Union Territory of Delhi, and the union territories other than Delhi (combining the six smaller union territories of Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep, and Puducherry). The state of Jammu and Kashmir was divided into two union territories in August, 2019. Because we are reporting findings up to 2017, we report findings for the state of Jammu and Kashmir. We also present findings for three groups of states categorised on the basis of their Socio-demographic Index (SDI) as calculated by GBD.

SDI is a composite indicator of development status, which ranges from 0 to 1, and is a geometric mean of the values of the indices of lag-distributed per capita income, mean education for those 15 years of age or older, and total fertility rate in people younger than 25 years. We assessed the relationship of each malnutrition indicator with the SDI value of the states in 2017. The states were categorised into the three state groups on the basis of their SDI in 2017: low SDI (≤0·53), middle SDI (0·54–0·60), and high SDI (>0·60; appendix p 38).

We assess the rates and proportion of deaths and DALYs attributable to child and maternal malnutrition among children younger than 5 years and DALYs attributable to child and maternal malnutrition among all ages in every state of India in 2017, and compare them with other risk factor categories. We also report cause-specific DALYs in children younger than 5 years attributable to malnutrition and its components in India in 2017. We present the prevalence of the eight malnutrition indicators included in Indian and global targets in the states of India. The targets set by the NNM 2022 and the WHO and UNICEF 2030 are summarised in the panel. We applied these targets to each state of India.PanelTargets set by the National Nutrition Mission for 2022 and WHO and UNICEF for 2030National Nutrition Mission 2022 targets

• Low birthweight: 2 percentage point reduction in prevalence annually from 2017 to 2022

• Child stunting: prevalence of 25% in 2022

  *The National Nutrition Mission 2022 target for stunting and underweight is for children aged 0–6 years; for consistency with the global targets we estimated this for children younger than 5 years.

• Child underweight: 2 percentage point reduction in prevalence annually from 2017 to 2022
• Anaemia: 3 percentage point reduction in prevalence annually in children younger than 5 years and in women 15–49 years of age from 2017 to 2022

  †The National Nutrition Mission 2022 target for child anaemia is for children aged 6–59 months; for consistency with the other targets we estimated this for children younger than 5 years.

WHO and UNICEF 2030 targets

• Low birthweight: 30% reduction in prevalence from 2012 to 2030

• Child stunting: 50% reduction in number of children younger than 5 years of age who are stunted from 2012 to 2030

  ‡We estimated a relative reduction in the prevalence of stunting instead of the absolute numbers for consistency with other indicators, because all other targets are based on prevalence.

• Child wasting: prevalence of less than 3% by 2030

• Anaemia: 50% reduction in prevalence in women 15–49 years of age from 2012 to 2030

• Breastfeeding: prevalence of exclusive breastfeeding in the first 6 months of at least 70% by 2030

• Child overweight: prevalence of less than 3% by 2030

We estimated the annualised percentage change in mid-year estimates of the prevalence of malnutrition indicators for the state SDI groups for three periods: 1990–2000, 2000–10, and 2010–17, and compared the annualised percentage change during 2010–17 with the annualised reduction needed to meet the NNM 2022 and the WHO and UNICEF 2030 targets in each state of India.

We projected the prevalence of malnutrition indicators for India and each state up to 2030 on the basis of the trends from 1990 to 2017. The annualised change for the projections for 2018–30 was calculated using a weight function that gave higher weight to the more recent trends in each state. The detailed methods used for these projections, including the out-of-sample predictive validity test, are described in the appendix (p 23) and elsewhere.

We report estimates with 95% uncertainty intervals (UIs) where relevant. The UIs were based on 1000 runs of the models for each quantity of interest, which have been found to be adequate for the GBD models (appendix p 23 and pp 44–49).

The mean of these distributions was regarded as the point estimate, and the 2·5th and 97·5th percentiles were considered the 95% UI.

Role of the funding source

Some staff of the Indian Council of Medical Research are co-authors on this paper, having contributed to various aspects of the study and analysis. The other funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of this paper. The corresponding author had full access to all of the data in the study and had final responsibility for the decision to submit for publication.

Results

Malnutrition burden

Of the 1·04 million under-5 deaths in India in 2017, 706 000 (95% UI 659 000–759 000; 68·2%, 65·8–70·7) could be attributed to malnutrition.

Although all-cause under-5 death rate in India decreased from 2336 per 100 000 (2271–2405) in 1990 to 801 per 100 000 (759–850) in 2017, the proportion of under-5 deaths attributable to malnutrition changed only modestly from 70·4% (67·0–74·0) in 1990 to 68·2% (65·8–70·7) in 2017.

Similarly, the DALY rate attributable to malnutrition in children younger than 5 years reduced by 65·8% (62·9–68·7) from 147 956 per 100 000 (139 350–156 327) in 1990 to 50 627 (47 301–54 199) in 2017, but the proportion of total DALYs in children younger than 5 years attributable to malnutrition changed only slightly from 70·1% (66·8–70·6) in 1990 to 67·1% (64·9–69·4) in 2017, making it the predominant risk factor for health loss (appendix p 39). The vast majority of the malnutrition DALYs in children younger than 5 years in 2017 were due to mortality (94·5% of YLLs, 5·5% of YLDs).

Although the relative contribution of child and maternal malnutrition to total DALYs across all ages has declined in India from 36·5% (95% UI 34·5–38·4) in 1990 to 17·3% (16·3–18·2) in 2017, it is still the leading risk factor for health loss (appendix p 39). The population of 1·38 billion in India in 2017 made up 18·1% of the global population, but India had 25·4% of the total global DALYs attributable to child and maternal malnutrition in 2017.

Malnutrition was the leading risk factor in children younger than 5 years in every state of India in 2017 (appendix p 39). The DALY rate attributable to malnutrition in children younger than 5 years varied 6·8 times between the states, and it was 1·8 times higher in the low SDI than in the middle SDI state groups and 2·4 times higher than in high SDI state groups (figure 1, appendix p 39). Malnutrition was also the leading risk factor across all ages in 23 states that comprised 64% of India's population in 2017, contributing 10·0%–26·4% of the total DALYs (appendix p 40). The DALY rate attributable to malnutrition across all ages varied 6·0 times between states, and it was 2·0 times higher in the low SDI than in the middle SDI state groups and 2·7 times higher than in high SDI state groups (appendix p 40).