Presentation made at a two-day workshop "Stepping up to India’s Nutrition Challenge: The Critical Role of Policy Makers" for district administrators from India’s Aspirational Districts, on 6-7 Aug 2018, at Mussoorie.

1. Transforming Nutrition: Ideas, Policy and Outcomes
Addressing the multiple determinants of
malnutrition: the role of nutrition
sensitive programmes and policies
Day 2, Session 1
7 August 2018

2. Many underlying determinants contribute to difference in stunting
between very high‐burden & low-burden districts, 2016
Source: Understanding the geographical burden of stunting in India: A regression‐decomposition analysis of district‐level data from
2015–16; Authors: Purnima Menon, Derek Headey, Rasmi Avula, and Phuong Hong Nguyen

3. Lancet 2013 conceptual framework
3

4. A framework for maximizing nutrition
sensitivity of other sectors
Ruel and Alderman (Lancet, 2013) outline three approaches that
programs in other sectors can take to have a greater impact on
nutrition, i.e. be more ‘nutrition-sensitive’.
1. addressing the underlying determinants of fetal and
childhood nutrition and development
2. incorporate specific nutrition goals and actions
3. serve as delivery platforms for nutrition-specific interventions
CRITICAL SECTORS: SOCIAL PROTECTION, AGRICULTURE,
EDUCATION, GENDER
Ruel, Marie T., and Harold Alderman. "Nutrition-sensitive interventions and programmes: how can they help to
accelerate progress in improving maternal and child nutrition?." The Lancet (2013).g

5. New review (2018)
• Nutrition-sensitive agricultural programs (NSAP) improve a variety of nutrition
outcomes in both mothers and children, especially when these programs include
nutrition and health behavioral change communications (BCC) and carefully designed
interventions to empower women.
• Greater benefits achieved when programs also incorporate actions to improve health
and WASH practices and to provide specially formulated fortified products to address
children’s high nutrient requirements in areas where access to nutrient-rich foods is
limited.
• Stunting impacts very limited…but is it feasible to expect?
• Improving diets for all household members is a much more logical, reasonable, and
achievable goal for agriculture than addressing childhood stunting,
• Context is key in determining how, to what extent, and under what conditions
agriculture impacts nutrition.
Ruel, M., Quisumbing, A and Balagamwala, M. (2018) Nutrition-sensitive agriculture:
What have we learned so far? Global Food Security

6. But we need to go beyond agriculture, to
Food systems
Global Panel Foresight Report 2016
6

7. Food systems need to make it
easier to make nutritious food
choices
• Food systems not intrinsically geared
towards nutrition
• While consumers have co-
responsibility, they make choices in
their immediate food environment
• How available, affordable, desirable
and safe are their choices?
7

8. 8
Prevention
Promotion
Helping to protect against
poverty
Helping to prevent falling into
poverty
Helping to move people out
of poverty
Protection
Transformation
Helping to address
structural drivers of poverty
and inequality
SOCIALASSISTANCE
SOCIALINSURANCE
LABOURMARKETPOLICIES

9. Social protection and nutrition: mixed
evidence
9
Lack of impact due to:
• Short duration of transfers
• Lack of linkages to nutrition
interventions
• Poor quality of health and
nutrition services
• Lack of consideration of
caregivers’ time constraints
Ruel & Alderman 2013; Alderman
2014
Pathways for nutrition-
sensitive social protection:
1) Increasing incomes through
cash
2) Providing subsidies and price
supports
3) Addressing preferences and
behaviours
Alderman 2015

10. What is the current state of evidence in India?
Approach one Approach two Approach three
Address the
underlying
determinants
Incorporate specific
nutrition goals and
actions
Delivery platforms
for nutrition-
specific
interventions
| | |
Public distribution
system (PDS)
___
Strong
(numerous
studies)
Weak
(7 studies)
None
| | |
Mid-day meal
scheme (MDMS)
___
Weak
(4 studies)
Weak
(6 studies)
Weak
(1 study)
| | |
Mahatma Gandhi
national rural
employment
guarantee scheme
(act) (MGNREGA)
___
Weak
(7 studies)
None None
Raghunathan et al. Economic and Political Weekly, 2017

11. Stopping transmission of fecal matter into the mouths
of human beings is the primary goal of WASH
interventions! FIVE F’s
Source: Perez et al., 2012
11

12. Recent evidence on WASH
intervention impact on
malnutrition NOT promising
• 3 large randomized controlled
trials published in 2018
• Combinations of nutritional
supplements, behaviour change
communication and WASH (pit
latrines, Tippy taps, promotion)
• None of the trials found an ADDED
benefit of the WASH interventions
over the nutritional supplement
and behaviour change
• Stunting/growth retardation
remained high
12

13. Gender & patriarchy are major contributor to
malnutrition in India (recognized in 1996!)
• It’s not as much about boy-girl differences in
malnutrition. It’s much more about how girls and
women are invested in and supported throughout
their lives!
13
Girls
• Education
• Age at marriage
• Nutrition
Women
• Health
• Nutrition
• Economic
opportunities
Pregnant
women/mothers
• Care during and
after pregnancy
• Support

14. Underweight women in India vs. Sub Saharan Africa
14
Coffey, PNAS 2015
INDIA
SUB-SAHARAN AFRICA

15. INPUTS PROCESSES OUTPUTS
INCOME PATHWAY
AGRICULTURE PATHWAY
HEALTH & NUTRITION BEHAVIOR CHANGE PATHWAY
RIGHTS PATHWAY
Savings & credit
training
Bank linkages
Loans taken, assets
purchased
Household income
Asset accumulation
Consumption smoothing
OUTCOMES
IMPACTS
 Resilience to shock
 Food access
 Food security
 Intake of diverse, nutrient-rich foods
 Nutrient absorption
 Seeking healthy, diverse foods
 Hygiene
 Disease burden (due to hygiene)
 IYCF practices
 Micronutrient status
 Anemia
 Child stunting
 Child underweight
 Child wasting
 Newborn health
BUILDINGSOCIALCAPITAL|TAKINGCOLLECTIVEACTION|EMPOWERINGWOMEN
Natural resource management
Agricultural planning,
seeds, technologies
Harvesting from
common resources
Crop variety
Poultry, livestock, fish rearing
Food production
Sale of food
Health and nutrition
information
Awareness and knowledge
Social support
Change in social norms
Behavior change
Social
accountability
training
Interactions with
service providers
Demand generation
Use of services
Service quality
Healthy maternal BMI
Kumar et al., under review, Global Food Security
SELF HELP GROUPS: Our recent review shows that pathways are
complex, impacts on stunting are uncertain but potentially good
platform for behaviour change
Kumar et al., Global Food Security, 2017

16. Photo: P. Menon, UP, 2013
Improving
immediate
conditions
By scaling up
nutrition-
specific
interventions
to improve
essential
actions
Improving underlying home
and community conditions
through
strengthening and linking up
key sectors that are already
ramping up programs:
Food security and quality
Sanitation
Income
Women’s empowerment and
education
Health and other services
Economic growth because it
puts more resources in the
hands of families.
Enbling environment: leadership, commitment, capacity, accountability
Critical question is how to put in place *at the same time* and at the same place,
for the same mother-child dyad* the conditions at both the underlying and
immediate levels to reach adolescents, women and children?
A key challenge for policy is how to bring it all together,
without negative consequences (e.g., overweight!)

17. The challenge of multisectoral action lies in
implementation & bringing it all together for the
ultimate convergence!
Basic
causes/enabling
environment
•Leadership
•Commitment
•Financing
•Knowledge
systems/learning
Underlying causes
•Economic
growth/jobs
•PDS
•Livelihoods programs
•Sanitation mission
•Gender/women’s
programs
•Girls education/MDM
Immediate causes
•Health
•ICDS
•SHGs
•Media

18. SUMMARY
 Malnutrition burden in India remains high despite some progress,
with tremendous inter-state and inter-district variability and multiple
drivers of disparity
 Stunting differences are not explained by any single factor, but
rather by a multitude of economic, health, hygiene and demographic
factors.
 Many success stories across India! Several states (Chhattisgarh,
Arunachal Pradesh) are among high performers on stunting reduction.
 Multiple forms of malnutrition – with several common drivers –
health, food and physical environments