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Background: To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring.Objectives: This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package.Methods: We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling.Results: Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%).Conclusions: Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact. [ABSTRACT FROM AUTHOR]

Gender disparities in child undernutrition and mortality in India have been a topic of interest for a long time, but little is known on trends or geographic variability in recent periods. We examined the degree to which historic patterns in gender disparities in child undernutrition and mortality in India have persisted given recent progress in health and nutrition. Using two nationally representative datasets from India between 2006 and 2016, we estimated mortality rates and stunting by gender and by birth order among children under 5 years old. We then tested for differences between boys and girls within each survey round for both national and state levels using bootstrapped standard errors, controlling for cluster and sampling weights. We found striking progress in child mortality and stunting in India between 2006 and 2016 for both boys and girls. Boys were more likely to die than girls during the first year of life. Girls had a higher risk of mortality between age 1 and 5 years than boys in 2006, but the improvements in survival eliminated this gender gap in 2016. For stunting, we found no gender difference in 2006, but girls had higher height‐for‐age Z‐scores (HAZ) and lower stunting than boys in 2016. Trends in gender gaps in mortality and stunting vary substantially by birth order and between states. Our findings indicate that improvements in mortality and nutritional status among girls have started to close gender disparities. Policy efforts to close gaps must stay the course in states that have made progress and be accelerated in states where disparities are still prominent. [ABSTRACT FROM AUTHOR]

Rapid urban expansion has important health implications. This study examines trends and inequalities in undernutrition and overnutrition by gender, residence (rural, urban slum, urban non-slum), and wealth among children and adults in India. We used National Family Health Survey data from 2006 and 2016 (n = 311,182 children 0-5y and 972,192 adults 15-54y in total). We calculated differences, slope index of inequality (SII) and concentration index to examine changes over time and inequalities in outcomes by gender, residence, and wealth quintile. Between 2006 and 2016, child stunting prevalence dropped from 48% to 38%, with no gender differences in trends, whereas child overweight/obesity remained at ~7–8%. In both years, stunting prevalence was higher in rural and urban slum households compared to urban non-slum households. Within-residence, wealth inequalities were large for stunting (SII: -33 to -19 percentage points, pp) and declined over time only in urban non-slum households. Among adults, underweight prevalence decreased by ~13 pp but overweight/obesity doubled (10% to 21%) between 2006 and 2016. Rises in overweight/obesity among women were greater in rural and urban slum than urban non-slum households. Within-residence, wealth inequalities were large for both underweight (SII -35 to -12pp) and overweight/obesity (+16 to +29pp) for adults, with the former being more concentrated among poorer households and the latter among wealthier households. In conclusion, India experienced a rapid decline in child and adult undernutrition between 2006 and 2016 across genders and areas of residence. Of great concern, however, is the doubling of adult overweight/obesity in all areas during this period and the rise in wealth inequalities in both rural and urban slum households. With the second largest urban population globally, India needs to aggressively tackle the multiple burdens of malnutrition, especially among rural and urban slum households and develop actions to maintain trends in undernutrition reduction without exacerbating the rapidly rising problems of overweight/obesity. [ABSTRACT FROM AUTHOR]

Background: India is facing a dual burden of undernutrition and overweight/obesity, and there are gaps in our understanding of the driving factors over time.Objective: This study examined the national and state trends for BMI and identified the determinants of underweight and overweight/obesity among adolescent girls and women.Methods: We used India's National Family Health Surveys data collected in 2005-2006 (n = 110,887) and 2015-2016 (n = 645,193). We applied multiple regression and decomposition analysis to assess determinants of underweight (BMI z score <  -1 SD; <18.5 kg/m2) and overweight/obesity (BMI z score >1 SD; ≥25 kg/m2).Results: Over the past decade, the prevalence of underweight decreased (43% to 38% and 33% to 19%) and the prevalence of overweight/obesity increased (3% to 5% and 15% to 24%), among adolescents and women, respectively, with high heterogeneity across states. Factors associated with a lower prevalence of underweight among women included higher socioeconomic status (SES) (OR: 0.35; 95% CI: 0.31, 0.41), urban residence (OR: 0.49; 95% CI: 0.45, 0.54), improved diet diversity (OR: 0.75; 95% CI: 0.69, 0.82), and latrine use (OR: 0.76; 95% CI: 0.70, 0.82). Higher education levels, decision-making, and ownership of money were also associated with a lower prevalence of underweight. Factors positively associated with overweight/obesity among women included SES (OR: 3.24; 95% CI: 2.81, 3.73), urban residence (OR: 2.23; 95% CI: 2.05, 2.42), diet diversity (OR: 1.21; 95% CI: 1.10, 1.32), latrine use (OR: 1.31; 95% CI: 1.21, 1.43), and education (OR: 1.39; 95% CI: 1.24, 1.55). Adolescents shared similar determinants to women. Overall, SES was a key driver of changes in women's BMI, explaining 29% of the reduction in undernutrition and 46% of the increase in overweight/obesity.Conclusions: Despite overall declines, regional and age disparities remain in the overall burden of underweight and the increases in overweight/obesity are concerning. The identified divergent risk factors (SES, residence, diet, education) highlight that simply improving economic status will not ensure healthy BMI status for women and girls. Balanced multidisciplinary approaches are needed to address both undernutrition and overweight. [ABSTRACT FROM AUTHOR]

Background The Minimum Dietary Diversity for Women (MMD-W) was validated as a proxy of micronutrient adequacy for nonpregnant women, with proposed data collection being either a list-based or a qualitative open recall method. Few studies have compared the performance of these 2 methods. Objectives We compared performance in predicting micronutrient adequacy of food group indicators (FGIs) measured by the list-based and the quantitative open recall methods using varying quantity cut-offs. We also examined the agreement between list-based and open recall FGIs. Methods Data were collected in Bangladesh (n  = 600 pregnant women) and India (n  = 655). The performance of different indicators to predict micronutrient adequacy was compared using receiver operating characteristic (ROC) analysis. Correlations between list-based and open recall FGIs were calculated using Spearman's rank test; agreement was assessed by the intraclass correlation coefficient (ICC) and kappa statistics. Food groups that were most often misreported by the list-based method were identified. Results There were no statistically significant differences in ROC curves between list-based and open recall FGIs in either country. In Bangladesh, correlations between list-based and open recall FGIs varied between 0.6 and 0.8; ICC values were 0.43–0.75; kappa values were 0.51–0.53 when using a cut-off of any quantity or 15 g for open recall, but were lower (k = 0.24) with the cut-off of 1 portion. In India, these values were lower: ∼0.4 for correlation, 0.32–0.37 for ICCs, and 0.17–0.22 for kappas. Food groups most susceptible to misreporting using the list-based method were beans/peas in Bangladesh and other vegetables in India. Conclusions Our study provides initial support for the use of list-based questionnaires in assessing food group diversity or prevalence of MDD-W in pregnant women. Additional and context-specific work may be required to understand the potential of simple methodologies to assess consumption of specific food groups. This trial was registered at clinicaltrials.gov as NCT02745249 (Bangladesh) and NCT03378141 (India). [ABSTRACT FROM AUTHOR]

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change. [ABSTRACT FROM AUTHOR]

Limited evidence exists on socio‐economic status (SES) inequalities in infant and young child feeding (IYCF) in India. We examine trends and changes in inequalities for IYCF practices over 2006–2016 and identify factors that may explain differences in IYCF across SES groups. We use data from the 2015–2016 and 2005–2006 National Family Health Surveys (n = 112,133 children < 24 months). We constructed SES quintiles (Q) and assessed inequalities using concentration and slope indices. We applied path analyses to examine the relationship between SES inequalities, intermediate determinants, and IYCF. Breastfeeding improved significantly over 2006–2016: from 23% to 42% for early initiation of breastfeeding (EIBF) and 46% to 55% for exclusive breastfeeding (EBF). Minimum dietary diversity (MDD) improved modestly (15% to 21%), but adequate diet did not change (~9%). Large SES gaps (Q5–Q1) were found for EIBF (8–17%) and EBF (−15% to −10%) in 2006; these gaps closed in 2016. The most inequitable practices in 2006 were MDD and iron‐rich foods (Q5 ~ 2–4 times higher than Q1); these gaps narrowed in 2016, but levels are low across SES groups. Factors along the path from SES inequalities to IYCF practices included health and nutrition services, information access, maternal education, number of children < 5 years, and urban/rural residence. The improvements in breastfeeding and narrowing of equity gaps in IYCF practices in India are significant achievements. However, ensuring the health and well‐being of India's large birth cohort will require more efforts to further improve breastfeeding, and concerted actions to address all aspects of complementary feeding across SES quintiles. [ABSTRACT FROM AUTHOR]

Suboptimal dietary intake is a critical cause of poor maternal nutrition, with several adverse consequences both for mothers and for their children. This study aimed to (1) assess maternal dietary patterns in India; (2) examine enablers and barriers in adopting recommended diets; (3) review current policy and program strategies to improve dietary intakes. We used mixed methods, including empirical analysis, compiling data from available national and subnational surveys, and reviewing literature, policy, and program strategies. Diets among pregnant women are characterized by low energy, macronutrient imbalance, and inadequate micronutrient intake. Supply- and demand-side constraints to healthy diets include food unavailability, poor economic situation, low exposure to nutrition counselling, food restrictions and taboos, adverse family influence and gender norms, and gaps in knowledge. Intervention strategies with potential to improve maternal diets include food-based programs, behavior change communication, and nutrition-sensitive agriculture interventions. However, strategies face implementation bottlenecks and limited effectiveness in real-world at-scale impact evaluations. In conclusion, investments in systems approaches spanning health, nutrition, and agriculture sectors, with evaluation frameworks at subnational levels, are needed to promote healthy diets for women.

Objectives: Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through the continuum of care in India between 2006 and 2016 and and (2) assessed inequalities in these opportunity gaps., Methods: We used two rounds of the National Family Health Survey data from 2005 to 2006 and 2015-2016 (n=36 850 and 190 898 mother-child dyads, respectively). We examine the opportunity gaps over time for seven nutrition interventions and their associated delivery platforms at national and state levels. We assessed equality and changes in equality between 2006 and 2016 for opportunity gaps by education, residence, socioeconomic status (SES), public and private platforms., Results: Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms; opportunity gaps ranging from 9 to 32 percentage points (pp) during the pregnancy, 17 pp during delivery and 9-26 pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators, but coverage increases for nutrition interventions was lower than for associated delivery platforms. The opportunity gaps were larger among women with higher education (22-57 pp in 2016), higher SES status and living in urban areas (23-57 pp), despite higher coverage of most interventions and the delivery platforms among these groups. Opportunity gaps vary tremendously by state with the highest gaps observed in Tripura, Andaman and Nicobar islands, and Punjab for different indicators., Conclusions: India's progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equality gaps remained. It is critical to close these gaps by addressing policy and programmatic delivery systems bottlenecks to achieve universal coverage for both health and nutrition within the delivery system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Adolescent pregnancy and child undernutrition are major social and public health concerns. We aimed to examine associations between adolescent pregnancy and child undernutrition in India, where one in five adolescents live, and one in three of the world's stunted children., Methods: Data were from India's fourth National Family Health Survey, 2015-16. Primiparous women aged 15-49 years who gave birth between 2010 and 2016 were classified on the basis of age at first birth: 10-19 years (adolescence), 20-24 years (young adulthood), and 25 years or older (adulthood). Primary outcomes were anthropometric measures of offspring undernutrition. Multivariable regression and structural equation models were used to understand the extent to which these measures were linked to adolescent pregnancy and the potential social, biological, and programmatic pathways., Findings: Of the 60 096 women in the sample, 14 107 (25%) first gave birth during adolescence. Children born to adolescent mothers had lower Z scores for length or height-for-age (mean difference -0·53 SD), weight-for-age (-0·40 SD), and weight-for-length or height (-0·16 SD) than children born to adult mothers. Compared with adult mothers, adolescent mothers were shorter (-1·21 cm, 95% CI -1·78 to -0·65), more likely to be underweight (18 percentage points, 15-21) and anaemic (8 percentage points, 6-11), less likely to access health services (-4 to -15 percentage points), and had poorer complementary feeding practices (-3 to -9 percentage points). Adolescent mothers also had less education (-3·30 years, 95% CI -3·68 to -2·91), less bargaining power (-7 to -15 percentage points), and lived in poorer households (-0·66 SD, 96% CI -0·82 to -0·50) with poorer sanitation (-28 percentage points, -32 to -24). In the path analysis, these intermediate factors predicted child anthropometry, with the strongest links being mother's education (18%), socioeconomic status (13%), and weight (15%)., Interpretation: Children born to adolescent mothers are at risk of being undernourished. Adolescent pregnancy is related to child undernutrition through poor maternal nutritional status, lower education, less health service access, poor complementary feeding practices, and poor living conditions. Policies and programmes to delay pregnancy and promote women's rights could help break the intergenerational cycle of undernutrition through many routes., Funding: Bill & Melinda Gates Foundation through Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India, led by the International Food Policy Research Institute., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)