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For more insights read the blog by IDS researcher Dolf te Lintelo Naming, shaming and praising - Introducing HANCI

Stuart Gillespie, CEO of Transform Nutrition, comments on the view held by Dr Arvind Panagariya that India has no reason to be ashamed of its child malnutrition levels.

In the 1 December 2012 issue of India’s Tehelka magazine, Dr Panagariya of Colombia University reiterates his belief, first aired in an October 2011 Times of India op-ed, that “once we do our malnutrition numbers correctly, we will find that India has no more to be ashamed of its malnutrition level or the progress made in combating it than of other vital statistics such a life expectancy, IMR and MMR”. Drawing on a recent paper (Panagariya 2012) he claims that India’s nutrition data are flawed and high levels of child malnutrition in India are myth, not reality. But he makes several basic errors, of which we highlight four below (italicizing his statements in Tehelka).

1. First, he is mystified by the differences in the relationships between mortality and anthropometric indices between African countries and India.

 “When two sets of indicators lead to diametrically opposite conclusions, you either have a reasonable explanation for it or must reject one set of indicators…..when we compare Indian children to those from sub-Saharan Africa (SSA) in terms of life expectancy, infant mortality rate (IMR), under-five mortality rate and maternal mortality rate (MMR), they look significantly healthier than the latter. But the picture turns on its head when we compare them in terms of incidence of stunting (low height for age) and underweight (low weight for age). The contrast is nothing short of dramatic”

This is a slightly strange statement -- why should apples look like oranges? Mortality data measure mortality and anthropometric data measure child growth. India may be significantly better than many sub-Saharan African countries at keeping children alive, but survival does not automatically equate with adequate nutrition and growth.

2.   Second, he exaggerates the actual differences between India and Africa

 What do the current data show? According to the WHO nutrition database of nationally representative stunting data, the latest data (now 7 years old) puts India at 48%, while five years later – in 2010 -- Chad was at 39% child stunting. In his 2011 Times of India article, Panagariya compares India with the Central Africa Republic and with Lesotho in a similar vein, and yet all three countries have similar levels of stunting (CAR 43% in 2006, Lesotho 45% in 2005, India 48% in 2005). The WHO (which does not actually produce national estimates, as claimed by Panagariya – just regional and global estimates) has pointed out in several publications that the prevalence of child undernutrition (whether underweight or stunting) is improving in Asia (where India drives the trends given its size) while stagnating or deteriorating in Africa. (de Onis et al 2011).

3.   Third, he argues that India needs it own growth standard and should not be using the international standard.

 “what if Indian children are on average genetically shorter and lighter than the population from which the WHO standards are derived?”

There is no genetic reason for higher rates of stunting among children anywhere. This has been repeatedly shown for many years – ever since the “small but healthy?” hypothesis of David Seckler was roundly rebutted back in 1980. Among the many studies published on this topic (most recently WHO 2006), there is a classic one from the Nutrition Foundation of India published in 1991 (Agarwal et al 1991) that concluded that Indian children properly cared for grew similarly to the international (NCHS) reference population. Indeed, based on this study; India decided to start using the NCHS reference population.

The current WHO (2006) growth reference is derived from healthy children in Brazil, Ghana, India, Norway, Oman and USA. Panagariya claims “as expected, when comparing children of a given age and sex even within this healthy sample, heights and weights differed.” But this is not correct, as WHO (2006) show – there were striking similarities with regard to linear growth across growth reference sites (e.g. India versus Norway, etc).

4.   Fourth, Panagariya argues that the trend in stunting and underweight is actually quite positive in India

 A decline from 43% to 40% underweight over a seven year period (1998-2005) for a country in the midst of an economic boom is NOT a positive trend.

The reality is...

That many, many studies have shown that a key issue in India is that infants begin life with a disadvantage due to poor intrauterine growth. At birth one third of Indian infants and underweight and 20% are stunted (Mamidi et al 2011, Ramachandran and Gopalan 2011). Combining the nutritional deficits already suffered at birth with those that develop within the first two years of life will account for most undernutrition in Indai. What happens, or does not happen, in the crucial 1000 day "window of opportunity (pregnancy plus first two years of a child's life) will continue to drive the nutritional statistics in India or elsewhere.

 References

Agarwal, K.N. et al (1991) Growth Performance of Affluent Indian Children, Nutrition Foundation of India, Scientific Report No. 11.

De Onis, M., Blossner, M and Borghi, E. (2011) Prevalence and trends of stunting among pre-school children, 1990–2020. Public Health Nutrition, p1-7.

Mamidi, R.S et al (2011) Pattern of Growth Faltering and Recovery in Under Five Children in India using WHO growth Standards – A stuidy on first and third national family Health Surveys.  Indian paediatrics, March 15, pages 1-6.

Some further responses to Dr Panagariya:

• Purnima Menon was quoted in an article in the Washington Post  ‘Is India’s malnutrition crisis a myth?’, December 2012 about this issue
• Deepankar Basu and Amit Basole wrote an article ‘Is Child Malnutrition Overstated in India? A Reponse to Arvind Panagariya’ in Sanhati.com December 2012

At a recent nutrition meeting I realised that I don’t yet have a clear idea of where nutrition should fit into the next set of development goals.

I also realised that the wider nutrition community has not had this discussion either.

As many critical decisions will be made in the next 6 months, we need to get our act together.

So what are the options?

A preliminary set might look something like this:

1. Business as usual.
That is, the underweight indicator in the poverty and hunger MDG. This seems unsatisfactory given the ambiguity attached to underweight—improvements in it do not necessarily track healthy growth (e.g. overweight but short kids).

2. Nutrition as a separate MDG.
There is probably not enough political space for this, given that the MDG set is already health-heavy. But if there were space would this be a good thing? It would probably draw more resources to nutrition (that is what the health MDGs did, by most accounts) and heaven knows nutrition needs that. It would also be a goal that could be embraced by rich and poor countries alike, thus unifying the under and over nutrition sides of the coin and generating a truly global goal, leading the way on other goals that will have to be global. A battery of indicators would be used: stunting, wasting and a healthy range for underweight (young children) and body mass index (adolescents and adults). The World Health Assembly might be supportive of this given the stunting target they recently announced.

3. More nutrition indicators throughout the MDGs, but no MDG on nutrition.
This seems more politically feasible, but maybe less desirable for the reasons given above. If it were an option, what would go where? Stunting is a marker of chronic undernutrition, but it is also a marker for poverty and deprivation in general. It could be used as an indicator for MDG1, with the hope that its existence will bring nutrition interventions into the poverty frame as they are a proven way of moving a stunting MDG1 indicator in sustainable ways that which generate high benefit cost ratios. Did this happen with the underweight indicator? I don’t think so, but I could be wrong. But even if I am right, things might be different now with the energy of the SUN movement. Wasting could be used as an indicator of child ill-health—we know that kids with severe acute wasting are many times more likely to die as kids without. Ironically this could help the treatment of SAM be better rooted in the health sector (it does not have much traction there). Diet diversity could be an indicator of food security (quantity, indirectly and quality, directly) and of agricultural productivity (via income effects and via improved physical access to food where markets don’t work well). If we could measure resource use and ecosystem services, we could begin to think about sustainable diets.

There could be combinations of 1 and 3 and 2 and 3.

There are probably other options out there.

And then there is the case of targets and timelines: should the aspiration be to end undernutrition? To halt the increase in overnutrition? To halve both rates?

What do you think?

To comment on this please go to Lawrence's original blog in Development Horizons

Tuesday is World Food Day and – given that world food prices are once again making the headlines, it seems timely to be assessing the state of undernutrition in the world. But it’s also depressing to see a topic returning to the media front pages that should never have gone away. As David McNair blogged last week on Save the Children research  “high and volatile prices are the new normal” and we shouldn’t allow the recent spikes in 2008, 2010 and this year to detract from both the constant urgency required to address global food security and undernutrition; and the longer term measures and understanding needed to ensure a century not as scarred by undernutrition and famine as the last.

On World Food Day I will be meeting in Dhaka with partners from Bangladesh, India, Kenya, Ethiopia and the US to discuss our plans as part of an exciting new research consortium intended to transform thinking on nutrition relevant evidence in order to support the global effort to reduce undernutrition. Our work is intended to directly benefit the international momentum behind scaling up nutrition (SUN) or national efforts in countries such as India who have not signed up to SUN.

We’re shaping the research around three key research themes designed to tackle undernutrition holistically at its immediate, underlying and basic levels. The first, led by Shams el-Arifeen of ICDDR,B, is focusing on approaches for scaling up direct nutrition interventions. There is a great deal of evidence on what works (in terms of public health, food and care interventions) in order to treat child and maternal undernutrition at this ‘immediate’ level, but a great deal still to be understood about how to turn this evidence into action on the ground rapidly, cost-effectively and at scale.

Estimates suggest that direct interventions will only address one-third of stunting prevalence, with broader-based ‘indirect interventions’ needed to tackle the underlying drivers of undernutrition. So the second theme, led by John Hoddinott of IFPRI, is focusing on those wider ‘indirect’ interventions which are known to be effective, but where the evidence base is urgently in need of improvement. We need to know how to maximise interventions such as agriculture, social protection and women’s empowerment, so they are more nutrition-sensitive.

IDS are leading on the third theme on the ‘enabling environment’ for undernutrition reduction. Why are some countries so much better at tackling undernutrition where so many others are failing? We think this is down to the politics and governance of nutrition - to tackling multiple political deficiencies, including: the lack of resources dedicated to direct and indirect measures; the lack of capable leaders with a the right knowledge and the means to implement a good plan; the lack of visibility of the malnourished; and their lack of power to access and monitor even basic nutrition services.

So this work incorporates and builds on some existing and exciting new work by IDS and our partners to try to better understand, measure and enhance enabling environments for undernutrition reduction. Behind this jargon, we’re looking seriously for example at the political economy of nutrition in Kenya; or how to enhance methods to hold policy makers to accounton their nutrition commitments. In Dhaka we’ll be discussing research planned by consortium partners on identifying political/governance determinants of undernutrition via multi-country analysis and at a district level in India; on building capacity for public health nutrition education in Bangladesh, India and Kenya; and on how to make nutrition more visible using frontline health workers equipped with mobile phone reporting. I’m particularly excited about a major trial we’re planning on how to support better integrated nutrition services at a community level via getting the community to monitor and feedback to providers on how services are delivered.

Please keep an eye on the Transform Nutrition website for further information about our plans and research.

This blog was first posted on the IDS Povertics blog on 15 October 2012

Stuart outlines the questions that Transform Nutrition aims to answer, and the impact we hope to have.

It is interesting that not too many people here are talking about the Scaling Up Nutrition (SUN) movement. For example, when asked why they had not signed up to SUN, senior nutrition representatives from the South African Government said they were waiting for an invitation. Of course they don’t need an invitation—that’s the point.

There may be political reasons for South Africa not signing up--they don’t need the money, they might think the hassle of dealing with donors is not worth it, and making yourself accountable to a wide audience is not an easy decision to make—but I found the disconnect rather stunning.

We had a good session from Jane Badham on SUN 101 (Jane is South African and the lead of the SUN Advocacy and Communications Team), but the fact that the Congress needed a 101 session is telling. I think this may say as much about the Congress community as it does about SUN.

SUN is beginning to be driven by countries (see the latest progress report from the SUN Secretariat—although it would be good to have an independent progress assessment). Rubber is hitting roads, but it is taking time—and I would like to see Jane’s Advocacy and Communications Team work more at the national level.

But the Congress members need to find more ways to link to debates outside their countries—and I know this is not easy for many because of lack of staff, job responsibilities, freedom of expression, lack of travel opportunities and lack of IT access. The Congress is a good way of doing this, of course, but, admittedly as an uninformed outsider, I get the feeling that the Congress is not making the most of its potential clout.

For example, there is no "Declaration" coming out of the Congress. Where else do we have 800 nutrition professionals, the vast majority being from Africa? This is a fantastic opportunity to put pressure on African governments to do more to accelerate declines in stunting rates.

Remember that if stunting were an MDG indicator, based on current rates of progress–about 1 percentage point a decade (see De Onis et. al. 2011 in Public Health Nutrition)--Africa would meet its 2015 target in the 22nd Century.

And it is not as if there are no dynamic African nutrition leaders—there are many here (some I have met Anna Lartey, Beatrice Kawana, Esi Colecraft, Joyce Kinabo, Paul Amuna, Namukolo Covic, Julia Tagwireyi, Bridget Okoeguale, Brenda Namugumya and others)--but the job of a Congress is to make the whole greater than the sum of the parts.

What would a declaration look like? Some thoughts:

“We the 800 participants of the African Nutrition Congress call on Governments throughout Africa to:

• Recognise the centrality of the nutrition status of your citizens to the success of your nation. Nearly one third of child deaths will be prevented by improved nutrition status. The economic growth and poverty reduction of tomorrow depends on child growth today. Tackling infant undernutrition today will prevent health epidemics of middle age.
• Make nutrition one of your top priorities. Champion it at the highest levels. Create a space for it within decision making. Create a nutrition budget line item and commit to spending 10% of your budgets to it. Sign up with SUN.
• Spend a high percentage of the nutrition budget on strengthening national and subnational capacity to scale up nutrition. This means working with households, frontline workers, NGOs, researchers, private sector and policymakers to dispel myths and enable action.
• Monitor the activities of the private sector within your countries. This sector can be a force for good but it can also be a force for bad. Monitoring what they do and spend is difficult, but we can monitor what they say. If it is responsible, let’s applaud. If not, let’s expose.
• Monitor nutrition outcomes on an annual basis, just as you monitor economic progress year by year. Allow civil society to applaud progress or criticise lack of progress. Allow yourselves to be guided by new evidence. Allow others to monitor your commitments—it is a way of building trust with your citizens. Let us see if you do as you say before you ask anyone else to do as you say.”

Of course, the language might have to be more diplomatic!

This blog first appeared in Development Horizons, on 3 October.

• Increase the budget allocated to addressing undernutrition;
• Keep girls in school longer;
• Change the focus of the Integrated Child Service to serve children under twos;
• Make undernutrition a political priority, to ensure the multi-sectoral coordination needed.

The programme has been made possible by a grant from the UK Government. The news follows UK Prime Minister, David Cameron’s Olympic legacy event which secured global commitments to reduce undernutrition.

Undernutrition is the underlying cause of death for 2.6 million pre-school children every year; a third of all child deaths in that age group. For those who survive, poor nutrition undermines school performance and later earning capacity. While the human and economic costs are enormous, the rate of undernutrition reduction remains extremely slow. Using research-based evidence, Transform Nutrition aims to inspire effective action to address undernutrition.

David Nabarro. Source: World Bank 2009

“The case has been made for nutrition interventions, but these are not being scaled up fast enough,” explains David Nabarro, Special Representative of the UN Secretary General for Food Security and Nutrition. “Agriculture and social protection programmes have a major potential to improve nutrition, but this is rarely exploited. Addressing undernutrition can free millions of children to fulfil their potential. For this to happen, nutrition needs to be made a political and development priority. Transform Nutrition’s research agenda is designed to help make this happen.”

Over five years, from September 2012 to August 2017, Transform Nutrition will contribute nutrition-relevant evidence to accelerate the reduction in undernutrition. The focus of the research will be the highest burden regions of South Asia and sub-Saharan Africa, specifically Bangladesh, India, Ethiopia, and Kenya. At the centre of the research is the window of opportunity - a child’s first 1000 days from conception to 24 months- when interventions can have the greatest impact.

“Nobody is against addressing undernutrition, but it is an issue that has been neglected.” says Stuart Gillespie, CEO, of Transform Nutrition. “Political leaders, ministries and programme implementers need evidence to support more effective action. Our team, which includes world leaders in this field, can now start work on new research.”

Transform Nutrition is a consortium of international research partners. Led by the International Food Policy Research Institute, members include: Institute of Development Studies; International Centre for Diarrhoeal Disease Research, Bangladesh; Public Health Foundation of India; Save the Children; and the University of Nairobi.