JOURNAL ARTICLES

× Background
The double burden of malnutrition (DBM), characterized by concurrent undernutrition and overnutrition, is a growing global concern. Families share resources and eating behaviors and programs often target households, yet evidence of the DBM at the family level is scarce.
Objectives
This study examined trends and inequality in the intrahousehold DBM in India between 2006 and 2021.
Methods
Data were from 3 waves of India’s National Family Health Survey (NFHS 2006, 2016, and 2021). We examined 3 types of household member (with children aged <5 y) combinations: mother–child (N = 328,039 across 3 waves), father–child, and parent (mother and father)–child (N = 47,139 for each pair). The DBM was defined as one or more individuals with undernutrition (either wasting or stunting in children or underweight in adults) and one or more overweight individuals within the same household. DBM was examined over time, at national and subnational levels, and by residence and wealth. Results Nearly all DBM was in the form of an overweight parent and an undernourished weight or stunted child. The prevalence of parent–child DBM increased from 15% in 2006 to 26% in 2021. Father–child pairs experienced the most rapid DBM increase, from 12% in 2006 to 22% in 2021, an 83% increase, driven by increasing overweight among men. In 2021, the DBM was highest in North-Eastern and Southern states, and among relatively rich households from urban areas. The increase in the DBM was faster in rural areas and among poor households compared with that in urban areas and rich households. Urban–rural and rich–poor inequalities in the DBM have decreased over time. Conclusions The intrahousehold DBM has increased over time, affecting 1 in 4 households in India in 2021. Family-based interventions that can simultaneously address child underweight and parent overweight are required to address India’s increasing intrahousehold DBM.

× Background: Anemia and poor physical growth during adolescence have far-ranging consequences, but limited longitudinal evidence exists on how changes in these factors relate to changes in learning skills as adolescents mature.
Objectives: We examined the association between changes in anemia and physical growth during adolescence and learning outcomes.
Methods: We used longitudinal data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) project, which surveyed adolescents aged 10–19 years in northern India in 2015–16 and 2018–19 (n = 5963). We used multilevel mixed-effects logistic regression models to examine associations between changes in anemia/thinness/stunting status (four groups: never, improved, new, and persistent) and reading (ability to read a story) and math proficiency (ability to solve division problems) at follow-up.
Results: Persistent anemia and stunting were higher among girls than boys (46% vs.8% and 37% vs. 14%, respectively), but persistent thinness was lower (7% vs. 16%). Improvement in anemia, thinness and stunting was 1.4–1.7 times higher among boys than girls. Boys who were anemic in both waves were 74% (adjusted odds ratio [AOR] 0.26, 95% confidence interval [CI)]: 0.12,0.59) and 65% (AOR 0.35, 95%CI: 0.16,0.76) less likely to be able to read a story and solve division problems, respectively, compared to boys who were non-anemic in both waves. Persistent thinness in boys was negatively associated with both reading (AOR 0.37, 95% CI: 0.21,0.66) and math proficiency (AOR 0.27, 95% CI: 0.16,0.46). Persistent stunting contributed to lower reading and math proficiency in boys and girls (AORs: 0.29 to 0.46). Boys whose anemia or thinness status improved and girls whose stunting status improved had similar learning skills at follow-up as those who were never anemic/thin/stunted.
Conclusions: Persistent anemia, thinness and short stature during adolescence was associated with poor learning. Programs targeted at adolescents should contribute to nurturing environments that foster healthy growth and learning.

× Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22–47%), and maternal factors (15–30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households.

× Background: Women's self-help groups (SHGs) have become one of the largest institutional platforms serving the poor. Nutrition behavior change communication (BCC) interventions delivered through SHGs may improve maternal and child nutrition outcomes.
Objective: To understand the effects of a nutrition BCC intervention delivered through SHGs in rural India on intermediate outcomes and nutrition outcomes.
Methods: We compared 16 matched blocks where communities were supported to form SHGs and improve livelihoods; 8 blocks received a 3-year nutrition intensive (NI) intervention with nutrition BCC, agriculture- and rights-based information, facilitated by a trained female volunteer; another 8 blocks received standard activities (STD) to support savings/livelihoods. Repeated cross-sectional surveys of mother-child pairs were conducted in 2017-18 (n = 1609 pairs) and 2019-20 (n = 1841 pairs). We matched treatment groups over time and applied difference-in-difference regression models to estimate impacts on intermediate outcomes (knowledge, income, agriculture/livelihoods, rights, empowerment) and nutrition outcomes (child feeding, woman's diet, woman and child anthropometry). Analyses were repeated on households with at least one SHG member.
Results: 40% of women were SHG members and 50% were from households with at least one SHG member. Only 10% of women in NI blocks had heard of intervention content at endline. Knowledge improved in both NI and STD groups. There was a positive NI impact on knowledge of timely introduction of animal sourced foods to children (p<0.05) but not on other intermediate outcomes. No impacts were observed for anthropometry or diet indicators except child animal source food consumption (p<0.01). In households with at least one SHG member, there was a positive NI impact on child unhealthy food consumption (p<0.05). Conclusions: Limited impacts may be due to limited exposure or skills of volunteers, and a concurrent national nutrition campaign. Our findings add to a growing literature on SHG-based BCC interventions and the conditions necessary for their success.

× Anaemia control programmes in India are hampered by a lack of representative evidence on anaemia prevalence, burden and associated factors for adolescents. The aim of this study was to: (1) describe the national and subnational prevalence, severity and burden of anaemia among Indian adolescents; (2) examine factors associated with anaemia at national and regional levels. Data (n = 14,673 individuals aged 10–19 years) were from India's Comprehensive National Nutrition Survey (CNNS, 2016–2018). CNNS used a multistage, stratified, probability proportion to size cluster sampling design. Prevalence was estimated using globally comparable age- and sex-specific cutoffs, using survey weights for biomarker sample collection. Burden analysis used prevalence estimates and projected population from 2011 Census data. Multivariable logistic regression models were used to analyse factors (diet, micronutrient deficiencies, haemoglobinopathies, sociodemographic factors, environment) associated with anaemia. Anaemia was present in 40% of girls and 18% of boys, equivalent to 72 million adolescents in 2018, and varied by region (girls 29%–46%; boys 11%–28%) and state (girls 7%–62%; boys 4%–32%). Iron deficiency (ferritin < 15 μg/L) was the strongest predictor of anaemia (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [3.21,6.83]), followed by haemoglobinopathies (HbA2 > 3.5% or any HbS) (OR: 2.81, 95% CI: [1.66,4.74]), vitamin A deficiency (serum retinol <20 ng/ml) (OR: 1.86, 95% CI: [1.23,2.80]) and zinc deficiency (serum zinc < 70 μg/L) (OR: 1.32, 95% CI: [1.02,1.72]). Regional models show heterogeneity in the strength of association between factors and anaemia by region. Adolescent anaemia control programmes in India should continue to address iron deficiency, strengthen strategies to identify haemoglobinopathies and other micronutrient deficiencies, and further explore geographic variation in associated factors.

× Background: India’s 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes—(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children <12 months. Methods: We used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5–9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children <12 months and 2398 pregnant women from a panel of 841 villages. Results: Among pregnant women and mothers of children <12 months, recall of counselling specific to the trimester of pregnancy or age of the child as per ICDS guidelines was higher in both MP (11.5pp (95% CI 7.0pp to 16.0pp)) and Bihar (8.0pp (95% CI 5.3pp to 10.7pp)). Significant differences were observed in the proportion of mothers of children <12 months receiving adequate number of home visits as per ICDS guidelines (MP 8.3pp (95% CI 4.1pp to 12.5pp), Bihar: 7.9pp (95% CI 4.1pp to 11.6pp)). Coverage of children receiving growth monitoring increased in Bihar (22pp (95% CI 0.18 to 0.25)), but not in MP. No effects were observed on infant and young child feeding practices. Conclusion: The at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers.

× Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020.

× 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 (I-ANC) to standard (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 (PIP) and identified reasons for limited impacts of the A&T maternal nutrition intervention package.
Methods: We used mixed methods: frontline workers surveys (FLWs, n∼500); counseling observations (n = 407); and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed seven 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 versus S-ANC (90 vs.70%), but gaps remained for training content and refresher trainings. FLW's knowledge improvement was higher in I-ANC than S-ANC (22–36 percentage points), but knowledge on 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 vs. 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 were 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.

× Objectives: The COVID-19 pandemic has profound negative impacts on people’s lives, but little is known on its effect on household food insecurity (HFI) in poor setting resources. This study assessed changes in HFI during the pandemic and examined the interlinkages between HFI with child feeding practices and coping strategies.
Design: A longitudinal survey in December 2019 (in-person) and August 2020 (by phone).
Setting: Community-based individuals from 26 blocks in 2 districts in Uttar Pradesh, India.
Participants: Mothers with children <2 years (n=569). Main outcomes and analyses: We measured HFI by using the HFI Access Scale and examined the changes in HFI during the pandemic using the Wilcoxon matched-pairs signed-rank tests. We then assessed child feeding practices and coping strategies by HFI status using multivariable regression models. Results: HFI increased sharply from 21% in December 2019 to 80% in August 2020, with 62% households changing the status from food secure to insecure over this period. Children in newly or consistently food-insecure households were less likely to consume a diverse diet (adjusted OR, AOR 0.57, 95% CI 0.34 to 0.95 and AOR 0.51, 95% CI 0.23 to 1.12, respectively) compared with those in food-secure households. Households with consistent food insecurity were more likely to engage in coping strategies such as reducing other essential non-food expenditures (AOR 2.2, 95% CI 1.09 to 4.24), borrowing money to buy food (AOR 4.3, 95% CI 2.31 to 7.95) or selling jewellery (AOR 5.0, 95% CI 1.74 to 14.27) to obtain foods. Similar findings were observed for newly food-insecure households. Conclusions: The COVID-19 pandemic and its lockdown measures posed a significant risk to HFI which in turn had implications for child feeding practices and coping strategies. Our findings highlight the need for further investment in targeted social protection strategies and safety nets as part of multisectoral solutions to improve HFI during and after COVID-19.

× Adolescent birth is a major global concern owing to its adverse effects on maternal and child health. We assessed trends in adolescent birth and examined its associations with child undernutrition in Bangladesh using data from seven rounds of Demographic and Health Surveys (1996–2017, n = 12,006 primiparous women with living children <5 years old). Adolescent birth (10–19 years old) declined slowly, from 84% in 1996 to 71% in 2017. Compared with adult mothers (≥20 years old), young adolescent mothers (10–15 years old) were more likely to be underweight (+11 pp), have lower education (−24 pp), have less decision-making power (−10 pp), live in poorer households (−0.9 SD) with poorer sanitation (−15 pp), and have poorer feeding practices (10 pp), and were less likely to access health and nutrition services (−3 to −24 pp). In multivariable regressions controlled for known determinants of child undernutrition, children born to adolescents had lower height-for-age Z-scores (−0.29 SD for young and −0.10 SD for old adolescents (16–19 years old)), weight-for-age Z-score (−0.18 and −0.06 SD, respectively) as well as higher stunting (5.9 pp) and underweight (6.0 pp) than those born to adults. In conclusion, birth during adolescence, a common occurrence in Bangladesh, is associated with child undernutrition. Policies and programs to address poverty and improve women's education can help delay marriage, reduce early childbearing, and improve child growth.

× Malnutrition in all its forms continues to be a massive global challenge, and the past decade has seen a growing political attention to addressing malnutrition in different contexts. What has been largely missing so far, and is in growing demand from countries, is tangible, practical and rigorous insights and lessons (from other countries or contexts) on how to translate this burgeoning political momentum into effective policies and programme implementation strategies – and ultimately impact on the ground. This new climate of learning from experience and evidence led to the launch in 2015 of the Stories of Change initiative. This series presents a second wave of studies from six countries (Tanzania, Rwanda, Vietnam, Ghana, Burkina Faso, Nigeria,) and three Indian states (Chhattisgarh, Gujarat, Tamil Nadu). These provide clear evidence combined with compelling narratives on what drives success in addressing all forms of malnutrition – evidence that is necessary for turning global momentum into actual results on the ground. This introductory Opinion is published with the first set of papers. It will be followed by a thorough synthesis of papers as a conclusion of the Series. We hope that the lessons embedded in these Stories of Change will inform and inspire the deliberations and outcomes of the UN Food Systems Summit and the second Nutrition for Growth Summit to be held this year, and the actions of those in the global food and nutrition system working for positive change.

× Background: The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services.
Objectives: This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic.
Methods: We conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children <2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. Results: Compared with prepandemic, service provision reduced substantially during lockdown (83–98 percentage points, pp), except for home visits and take-home rations (∼30%). Most FLWs (68%–90%) restored service provision in July 2020, except for immunization and hot cooked meals (<10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼40%–90%), social distancing (80%), and using PPE (40%–50%) and telephones for communication (∼20%). On the demand side, service utilization reduced substantially (40–80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%). Conclusions: COVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh, India, despite adaptations to restore services. Strengthening logistical support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.

× Background: Maternal nutrition interventions are inadequately integrated into antenatal care (ANC). Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization through government ANC services.
Objectives: We compared nutrition-intensified ANC (I-ANC) with standard ANC (S-ANC) on coverage of nutrition interventions and maternal nutrition practices.
Methods: We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018–2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices.
Results: Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7–14 percentage points (pp)] and counseling on core nutrition messages (DID: 10–23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron–folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A–rich foods (10 pp, 11 g/d), other vegetables and fruits (22–29 g/d), and gestational weight gain (0.4 kg).
Conclusions: Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141.

× Background: In response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (clinicaltrials.gov NCT03378141). However, we have a limited understanding of providers’ experiences and challenges of collecting and using data for decision making.
Objective: To identify barriers and facilitators to the 1) collection of data and 2) use of data for decision-making.
Methods: In-depth interviews (N = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors and A&T staff in two districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (N = 103) were surveyed to assess data use experiences.
Results: Data were used to understand the reach of maternal nutrition services, estimate the demand for supplements and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision-making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW education level, political structure and lack of cooperation between FLWs and supervisors.
Conclusions: Use of data for decision-making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data collection efforts, the use of data to inform decision-making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.

× India has been on a steady march to address malnutrition in the last decade. The nutrition community has worked on building consensus on key actions, implementation platforms were put in place and financing for nutrition slowly increased. Under the strong leadership of the Prime Minister, a revolutionary program to address malnutrition was launched in 2018. As actions under the mission accelerated, the COVID-19 pandemic arrived in early 2020. Affecting health systems, food systems, nutrition programs, social safety nets, and the economy, the pandemic has the potential to exacerbate the challenge of malnutrition in multiple ways. India can mitigate some of the possible ways in which COVID-19 will affect malnutrition but will require strong leadership and continued commitment, adaptation of the national nutrition mission, strengthening of the social safety net and innovative evidence-based data to take informed decisions, implement them and ensure feedback to take necessary corrective action. In this article, we outline some challenges and key areas for action. We conclude that India's nutrition journey is too important to be derailed by a crisis like COVID-19. This is a clarion call for the nutrition community in India to rally strongly to support continued attention to malnutrition in all its forms, to generate relevant evidence, and to support and engage all of society to urgently and adequately address malnutrition in the context of the COVID-19 pandemic. We have come too far to turn back now.

× India has the world’s highest number of undernourished children and the largest school feeding program, the Mid-Day Meal (MDM) scheme. As school feeding programs target children outside the highest-return “first 1000-days” window, they have not been included in the global agenda to address stunting. School meals benefit education and nutrition in participants, but no studies have examined whether benefits carry over to their children. Using nationally representative data on mothers and their children spanning 1993 to 2016, we assess whether MDM supports intergenerational improvements in child linear growth. Here we report that height-for-age z-score (HAZ) among children born to mothers with full MDM exposure was greater (+0.40 SD) than that in children born to non-exposed mothers. Associations were stronger in low socioeconomic strata and likely work through women’s education, fertility, and health service utilization. MDM was associated with 13–32% of the HAZ improvement in India from 2006 to 2016.

× The COVID-19 pandemic is expected to have profound effects on healthcare systems, but little evidence exists on service provision, utilisation, or adaptations. This study aimed to (1) examine the changes to health and nutrition service delivery and utilisation in urban Bangladesh during and after enforcement of COVID-19 restrictions and (2) identify adaptations and potential solutions to strengthen delivery and uptake. We conducted longitudinal surveys with health care providers (n = 45), pregnant women (n = 40), and mothers of children <2 years (n = 387) in February 2020 (in-person) and September 2020 (by phone). We used Wilcoxon matched-pairs signed-rank tests to compare the changes before and during the pandemic. Services delivery for women and children which require proximity were severely affected; weight and height measurements fell by 20–29 percentage points (pp) for pregnant women and 37–57 pp for children, and child immunisations fell by 38 pp. Declines in service utilisation were large, including drops in facility visitations (35 pp among pregnant women and 67 pp among mothers), health and nutrition counselling (up to 73 pp), child weight measurements (50 pp), and immunisations (61 pp). The primary method of adaptation was provision of services over phone (37% for antenatal care services, 44%–49% for counselling). Despite adaptations to service provision, continued availability of routine maternal and child health services did not translate into service utilisation. Further investments are needed to provide timely and accurate information on COVID-19 to the general public, improve COVID-19 training and provide incentives for health care providers and ensure availability of personal protective equipment for providers and beneficiaries.

× Although many education and health programs aim to improve early childhood development, it is challenging to assess developmental levels of infants and small children through large household surveys. The Caregiver Reported Early Development Instruments (CREDI) has been proposed as an adaptable, practical, and low‐cost instrument for measuring the developmental status of children under 3 years of age at scale, as it is relatively short and collected by caregiver report. This study employed the CREDI to measure the development of a sample of 994 children ages 22–35 months in rural India and compared the results to those obtained using the Bayley Scales of Infant and Toddler Development (Bayley‐III), a reliable and widely used instrument, albeit one not always suited to large‐scale data collection efforts given its length, cost, and complexity of administration. The CREDI validation exercise showed that caregivers can provide assessments in keeping with the more interactive (hence more time‐consuming and training‐intensive) Bayley‐III instrument. Noteworthy, there was no indication that concordance of the instruments differed by education of the caregiver. This is important as it points to alternate feasible tools to measure child development outcomes through large‐scale surveys.

× The Integrated Child Development Services (ICDS) programme has been the central focus of the POSHAN Abhiyaan to combat maternal and child malnutrition under the national nutrition mission in India. This paper examined the linkages between utilization of ICDS and underweight among children aged 6-59 months. The study utilized data from two recent rounds of the National Family Health Survey (NFHS-4 [2015-2016] and NFHS-5 [2019-2021]). Descriptive analyses were used to assess the change in utilization of ICDS and the prevalence of underweight at the national and state levels. Multivariable logistic regressions were performed to examine factors associated with the utilization of ICDS and underweight. Linkages between utilization of ICDS and underweight were examined using the difference-in-differences (DID) approach. Utilization of ICDS increased from 58% in 2015-2016 to 71% in 2019-2021. The prevalence of underweight decreased from 37% to 32% in the same period. Changes in ICDS utilization and underweight prevalence varied considerably across states, socioeconomic and demographic characteristics. Results from decomposition of DID models suggest that improvements in ICDS explained 9%-12% of the observed reduction in underweight children between 2016 and 2021, suggesting that ICDS made a modest but meaningful contribution in addressing undernutrition among children aged 6-59 months in this period.

× Background
The double burden of malnutrition (DBM), characterized by concurrent undernutrition and overnutrition, is a growing global concern. Families share resources and eating behaviors and programs often target households, yet evidence of the DBM at the family level is scarce.
Objectives
This study examined trends and inequality in the intrahousehold DBM in India between 2006 and 2021.
Methods
Data were from 3 waves of India’s National Family Health Survey (NFHS 2006, 2016, and 2021). We examined 3 types of household member (with children aged <5 y) combinations: mother–child (N = 328,039 across 3 waves), father–child, and parent (mother and father)–child (N = 47,139 for each pair). The DBM was defined as one or more individuals with undernutrition (either wasting or stunting in children or underweight in adults) and one or more overweight individuals within the same household. DBM was examined over time, at national and subnational levels, and by residence and wealth. Results Nearly all DBM was in the form of an overweight parent and an undernourished weight or stunted child. The prevalence of parent–child DBM increased from 15% in 2006 to 26% in 2021. Father–child pairs experienced the most rapid DBM increase, from 12% in 2006 to 22% in 2021, an 83% increase, driven by increasing overweight among men. In 2021, the DBM was highest in North-Eastern and Southern states, and among relatively rich households from urban areas. The increase in the DBM was faster in rural areas and among poor households compared with that in urban areas and rich households. Urban–rural and rich–poor inequalities in the DBM have decreased over time. Conclusions The intrahousehold DBM has increased over time, affecting 1 in 4 households in India in 2021. Family-based interventions that can simultaneously address child underweight and parent overweight are required to address India’s increasing intrahousehold DBM.

× Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22–47%), and maternal factors (15–30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households.

× Background: Anemia and poor physical growth during adolescence have far-ranging consequences, but limited longitudinal evidence exists on how changes in these factors relate to changes in learning skills as adolescents mature.
Objectives: We examined the association between changes in anemia and physical growth during adolescence and learning outcomes.
Methods: We used longitudinal data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) project, which surveyed adolescents aged 10–19 years in northern India in 2015–16 and 2018–19 (n = 5963). We used multilevel mixed-effects logistic regression models to examine associations between changes in anemia/thinness/stunting status (four groups: never, improved, new, and persistent) and reading (ability to read a story) and math proficiency (ability to solve division problems) at follow-up.
Results: Persistent anemia and stunting were higher among girls than boys (46% vs.8% and 37% vs. 14%, respectively), but persistent thinness was lower (7% vs. 16%). Improvement in anemia, thinness and stunting was 1.4–1.7 times higher among boys than girls. Boys who were anemic in both waves were 74% (adjusted odds ratio [AOR] 0.26, 95% confidence interval [CI)]: 0.12,0.59) and 65% (AOR 0.35, 95%CI: 0.16,0.76) less likely to be able to read a story and solve division problems, respectively, compared to boys who were non-anemic in both waves. Persistent thinness in boys was negatively associated with both reading (AOR 0.37, 95% CI: 0.21,0.66) and math proficiency (AOR 0.27, 95% CI: 0.16,0.46). Persistent stunting contributed to lower reading and math proficiency in boys and girls (AORs: 0.29 to 0.46). Boys whose anemia or thinness status improved and girls whose stunting status improved had similar learning skills at follow-up as those who were never anemic/thin/stunted.
Conclusions: Persistent anemia, thinness and short stature during adolescence was associated with poor learning. Programs targeted at adolescents should contribute to nurturing environments that foster healthy growth and learning.

× Background: Women's self-help groups (SHGs) have become one of the largest institutional platforms serving the poor. Nutrition behavior change communication (BCC) interventions delivered through SHGs may improve maternal and child nutrition outcomes.
Objective: To understand the effects of a nutrition BCC intervention delivered through SHGs in rural India on intermediate outcomes and nutrition outcomes.
Methods: We compared 16 matched blocks where communities were supported to form SHGs and improve livelihoods; 8 blocks received a 3-year nutrition intensive (NI) intervention with nutrition BCC, agriculture- and rights-based information, facilitated by a trained female volunteer; another 8 blocks received standard activities (STD) to support savings/livelihoods. Repeated cross-sectional surveys of mother-child pairs were conducted in 2017-18 (n = 1609 pairs) and 2019-20 (n = 1841 pairs). We matched treatment groups over time and applied difference-in-difference regression models to estimate impacts on intermediate outcomes (knowledge, income, agriculture/livelihoods, rights, empowerment) and nutrition outcomes (child feeding, woman's diet, woman and child anthropometry). Analyses were repeated on households with at least one SHG member.
Results: 40% of women were SHG members and 50% were from households with at least one SHG member. Only 10% of women in NI blocks had heard of intervention content at endline. Knowledge improved in both NI and STD groups. There was a positive NI impact on knowledge of timely introduction of animal sourced foods to children (p<0.05) but not on other intermediate outcomes. No impacts were observed for anthropometry or diet indicators except child animal source food consumption (p<0.01). In households with at least one SHG member, there was a positive NI impact on child unhealthy food consumption (p<0.05). Conclusions: Limited impacts may be due to limited exposure or skills of volunteers, and a concurrent national nutrition campaign. Our findings add to a growing literature on SHG-based BCC interventions and the conditions necessary for their success.

× Anaemia control programmes in India are hampered by a lack of representative evidence on anaemia prevalence, burden and associated factors for adolescents. The aim of this study was to: (1) describe the national and subnational prevalence, severity and burden of anaemia among Indian adolescents; (2) examine factors associated with anaemia at national and regional levels. Data (n = 14,673 individuals aged 10–19 years) were from India's Comprehensive National Nutrition Survey (CNNS, 2016–2018). CNNS used a multistage, stratified, probability proportion to size cluster sampling design. Prevalence was estimated using globally comparable age- and sex-specific cutoffs, using survey weights for biomarker sample collection. Burden analysis used prevalence estimates and projected population from 2011 Census data. Multivariable logistic regression models were used to analyse factors (diet, micronutrient deficiencies, haemoglobinopathies, sociodemographic factors, environment) associated with anaemia. Anaemia was present in 40% of girls and 18% of boys, equivalent to 72 million adolescents in 2018, and varied by region (girls 29%–46%; boys 11%–28%) and state (girls 7%–62%; boys 4%–32%). Iron deficiency (ferritin < 15 μg/L) was the strongest predictor of anaemia (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [3.21,6.83]), followed by haemoglobinopathies (HbA2 > 3.5% or any HbS) (OR: 2.81, 95% CI: [1.66,4.74]), vitamin A deficiency (serum retinol <20 ng/ml) (OR: 1.86, 95% CI: [1.23,2.80]) and zinc deficiency (serum zinc < 70 μg/L) (OR: 1.32, 95% CI: [1.02,1.72]). Regional models show heterogeneity in the strength of association between factors and anaemia by region. Adolescent anaemia control programmes in India should continue to address iron deficiency, strengthen strategies to identify haemoglobinopathies and other micronutrient deficiencies, and further explore geographic variation in associated factors.

× Background: India’s 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes—(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children <12 months. Methods: We used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5–9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children <12 months and 2398 pregnant women from a panel of 841 villages. Results: Among pregnant women and mothers of children <12 months, recall of counselling specific to the trimester of pregnancy or age of the child as per ICDS guidelines was higher in both MP (11.5pp (95% CI 7.0pp to 16.0pp)) and Bihar (8.0pp (95% CI 5.3pp to 10.7pp)). Significant differences were observed in the proportion of mothers of children <12 months receiving adequate number of home visits as per ICDS guidelines (MP 8.3pp (95% CI 4.1pp to 12.5pp), Bihar: 7.9pp (95% CI 4.1pp to 11.6pp)). Coverage of children receiving growth monitoring increased in Bihar (22pp (95% CI 0.18 to 0.25)), but not in MP. No effects were observed on infant and young child feeding practices. Conclusion: The at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers.

× Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020.

× 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 (I-ANC) to standard (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 (PIP) and identified reasons for limited impacts of the A&T maternal nutrition intervention package.
Methods: We used mixed methods: frontline workers surveys (FLWs, n∼500); counseling observations (n = 407); and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed seven 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 versus S-ANC (90 vs.70%), but gaps remained for training content and refresher trainings. FLW's knowledge improvement was higher in I-ANC than S-ANC (22–36 percentage points), but knowledge on 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 vs. 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 were 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.

× Most research on the delivery of India’s Integrated Child Development Services programme in the period after the reforms has focused on performance in implementation of the programme by states,10 with limited evidence on individual and household uptake or use of the programme. In view of these gaps, we investigated changes in the use of the services over the continuum of care from pregnancy up to early childhood between 2006 and 2016. We assessed equity gaps and factors associated with use of services. Our analysis has policy implications for India, but also offers global lessons to other countries embarking on scalingup integrated programmes to address maternal and child health, nutrition and child development.

× 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.

× The global community is committed to addressing malnutrition. And yet, coverage data for high-impact interventions along the continuum of care remain scarce due to several measurement and data collection challenges. In this analysis paper, we identify 24 nutrition interventions that should be tracked by all countries, and determine if their coverage is currently measured by major household nutrition and health surveys. We then present three case studies, using published literature and empirical data from large-scale initiatives, to illustrate the kind of data collection innovations that are feasible. We find that data are not routinely collected in a standardised way across countries for most of the core set of interventions. Case studies—of growth monitoring and screening for acute malnutrition, infant and young child feeding counselling, and nutrition monitoring in India—highlight both challenges and potential solutions. Advancing the nutrition intervention coverage measurement agenda is essential for sustained progress in driving down rates of malnutrition. It will require (1) global consensus on a core set of validated coverage indicators on proven, high-impact nutrition-specific interventions; (2) the inclusion of coverage measurement and indicator guidance in WHO intervention recommendations; (3) the incorporation of these indicators into data collection mechanisms and relevant intervention delivery platforms; and (4) an agenda for continuous measurement improvement.

× The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005–6 (NFHS-3) for the base year and NHFS-4 2015–16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool.

× Uttar Pradesh (UP) is the most populous state with the highest burden of undernutrition in India. Alive & Thrive is working to strengthen behavior change communication (BCC) on diet diversity and quantity, using health systems platforms to deliver maternal nutrition intervention. However, evidence on the accessibility and affordability associated with recommended diets is limited. This study aims to: 1) examine the costs of nutritious foods in local markets, 2) identify inexpensive sources of essential micronutrients which could be promoted through BCC interventions.

× India accounts for approximately one third of the world's total population of stunted preschoolers. Addressing global undernutrition, therefore, requires an understanding of the determinants of stunting across India's diverse states and districts. We created a district‐level aggregate data set from the recently released 2015–2016 National and Family Health Survey, which covered 601,509 households in 640 districts. We used mapping and descriptive analyses to understand spatial differences in distribution of stunting. We then used population‐weighted regressions to identify stunting determinants and regression‐based decompositions to explain differences between high‐and low‐stunting districts across India.

× India carries the largest burden of anaemia globally. Progress to reduce anaemia has been slow despite substantial economic growth and 50 years of programmatic efforts. Identification of the factors that contribute to anaemia reductions is needed to accelerate progress. We examined changes in haemoglobin (Hb) and anaemia among women and children in India from 2006 to 2016 and identified drivers of changes in these outcomes over time.

× 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.