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Department of Medicine; Department of Population and Quantitative Health Sciences; Department of Pediatrics; Department of Psychiatry; Department of Obstetrics and Gynecology

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International Public Health | Nutritional and Metabolic Diseases | Nutritional Epidemiology | Pediatrics | Translational Medical Research


BACKGROUND: There is a lack of nationally representative estimates for the consequences of early childhood undernutrition on preadolescent outcomes in India. Understanding this relationship is helpful to develop interventions that not only prevent child undernutrition but also mitigate its consequences.

METHODS AND FINDINGS: In this cohort study, we analyzed prospectively gathered data from 2 waves of the India Human Development Survey (IHDS) to investigate the association of undernutrition during early childhood (0 to 5 years) in 2004 to 2005 with physical and cognitive outcomes during preadolescent (8 to 11 years) years in 2011 to 2012. These surveys interviewed 41,554 households across all 33 states and union territories in India in 2004 to 2005 and reinterviewed 83% of the households in 2011 to 2012. Primary exposure was assessed using the Composite Index of Anthropometric Failure (CIAF) based on 2004 to 2005 survey. Primary outcomes were short stature (height-for-age z-score [HAZ] < -2), thinness (body mass index [BMI] < 18.5 kg/m2), reading, and arithmetic skills during preadolescence based on the 2011 to 2012 survey. Survey-weighted generalized linear models were used, and effect modification based on child sex and sociodemographic variables were evaluated using 3-way interaction terms. Of the 7,868 children included in this analysis, 4,334 (57.3%) were undernourished. Being undernourished was associated with increased odds of short stature (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.45 to 2.06) and thinness (OR 1.52, 95% CI 1.33 to 1.73) during the preadolescent period, while it was associated with decreased odds of achieving a higher reading (cumulative odds ratio [cumOR]: 0.76, 0.66 to 0.87) and arithmetic (cumOR: 0.72, 0.63 to 0.82) outcomes. The disparity in outcomes based on CIAF increased with age, especially for female children. Increased level of female education within the household reduced the disadvantages of undernutrition among female children. Study limitations include observational and missing data, which limit our ability to draw strong causal inferences.

CONCLUSIONS: In this study, we found that early child undernutrition was associated with several adverse preadolescent physical and cognitive outcomes, especially among female children. Improved female education mitigates this association. Female education promotion should assume a central role in Indian public health policy making.


Malnutrition, Children, India, Nutrition, Educational attainment, Schools, Anthropometry, Body mass index, UMCCTS funding

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Copyright © 2021 Soni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Soni A, Fahey N, Bhutta ZA, Li W, Frazier JA, Moore Simas T, Nimbalkar SM, Allison JJ. Early childhood undernutrition, preadolescent physical growth, and cognitive achievement in India: A population-based cohort study. PLoS Med. 2021 Oct 27;18(10):e1003838. doi: 10.1371/journal.pmed.1003838. PMID: 34705825; PMCID: PMC8580255. Link to article on publisher's site

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PLoS medicine

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Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.