SAFANSI The South Asia Food and Nutrition Security Initiative public health in india and four states in transition An epidemiological transition is well underway transition between these states, and between in India, in common with countries throughout them and India as a whole, reveals patterns that much of the developing world. The transition can usefully inform local public health policy and refers to a change in the prevailing causes priority setting within them. Addressing the non- of illness (morbidity) and death (mortality) communicable diseases that today represent the that is often observed by demographers as leading risks to public health will entail determining economic development and technology enables how financial and other resources are most improvements in public health and sanitation. It appropriately disbursed to local governments and sees a substantial decline in the communicable their partners in the health industry. And yet, or infectious diseases that disproportionately even with their relative decline as causes of health afflict mothers and prenatal and young children, loss, the communicable diseases that were once including diarrheal and respiratory infections the leading risk factors warrant continued policy and nutrition deficiencies. Life expectancy focus because they remain among the top 10 increases, and the non-communicable, chronic causes of health loss and death in India and within diseases associated with older age—such as the four states examined here. Because there are diabetes, heart disease, and stroke—become the substantial differences in the burden of specific leading risk factors for disability and death. This diseases even between neighboring states, it is epidemiological shift necessitates a greater focus essential that the control of communicable and on the prevention and management of chronic non-communicable diseases be tailored to the conditions, such as cardiovascular diseases, epidemiological status of each state. diabetes, chronic respiratory diseases, mental health disorders, and cancers. Between 1990 and 2016, India experienced much of this process. In 1990, four of the five most prominent causes of illness and death were the results of communicable diseases, poor nutrition, and unsafe sources of drinking water. By 2016, these had given way to non-communicable illnesses relating to indoor and outdoor air pollution, high blood pressure, heart disease, and high blood sugar. While these now account for four of the five leading risk factors for health loss—measured in terms of disability-adjusted life years—in India, the scale of magnitude of the country obscures the wide diversity of conditions within its respective states. The north Indian states of Uttar Pradesh and Uttarakhand and the states of Meghalaya and Nagaland in India’s far northeast are important cases in point. The Portrait smiling indian children on Varkala during puja ceremony on holy difference in the rates of the epidemiological place - on the Papanasam beach - Alexandra Lande / Shutterstock.com June 2018 South Asia Region Life expectancy at birth, nationally, by state, and by sex India Meghalaya Nagaland Uttar Pradesh Uttarakhand 1990 2016 1990 2016 1990 2016 1990 2016 1990 2016 Both sexes 59.0 68.6 61.3 69.4 63.9 71.4 54.2 65.6 59.1 68.0 Males 58.3 66.9 59.8 66.8 63.1 69.1 54.9 64.6 57.8 65.3 Females 59.7 70.3 63.2 72.4 64.9 74.5 53.5 66.8 60.5 71.1 Contrasts between female and male health exhibited the lowest decline of the four states, indicators, and between indicators in the four from 13.6 to 9.7 deaths per 1,000 people during states and national-level, all-India averages the same period. Overall, lower birth and death are instructive, and many of the results of the rates will result in a relatively older population, burden of disease study are reported in these which require careful planning appropriate for the terms. The longer life expectancy typical of healthcare needs of the aging population. women over men and the rate at which this changes for the two sexes is clearly evidenced The 84 risk factors tracked by the global burden in the four states as it is elsewhere in India. of disease study are broadly classified into three Across India, life expectancy rose by 8.6 years types: metabolic, environmental, and behavioral. among males and by 10.6 years among females Metabolic risks include high blood pressure, between 1990 and 2016 – a two-year gap in high blood sugar, and obesity – measured by the increase. The period saw a dramatic, 13.3- body mass index. Environmental risks include year increase in female life expectancy in Uttar poor sanitation, unsafe water, air pollution, and Pradesh, which in 1990 had been the only Indian occupational risks associated with workplace state in which male life expectancy exceeded activities. Behavioral risks include malnutrition, female life expectancy. Male life expectancy in especially among mothers and small children, the state rose by 9.7 years during the 26-year poor diets, and consumption of alcohol, tobacco, period. The smallest increase in life expectancy and drugs. Those risks which account for a high took place among males in Nagaland, where it proportion of premature death and disability rose by 6 years. The differential in the change in adjusted life years are natural targets for public female and male life expectancy was the widest health policy and addressing them effectively in Uttarakhand, where it increased from 2.7 years can substantially reduce India’s overall disease in 1990 to 5.8 years in 2016. It is evident that the burden. As each state progresses through the epidemiological transition has different effects on epidemiological transition, targeting the most males and females, which suggests the need for significant risk factors is critical to improving careful attention to gender, even as overall health health outcomes. outcomes in India continue to improve. As of 2016, 31 percent of India’s disease burden Expressed in crude birth rates and age- was attributable to behavioral risk factors, standardized death rates, the demographic whereas metabolic risks accounted for 16 percent transition India is currently undergoing quickly and environmental risks for 17 percent. For becomes apparent. Between 1990 and 2015 the policy makers this suggests that communicable crude birth rate decreased from 32 to 19 births per and nutritional diseases warrant continued 1,000 people in India, while the age-standardized attention, while the increasing incidence of non- death rate per 1,000 people declined from 16.5 to communicable diseases places them as priorities 11.6. In Uttarakhand, this mortality rate fell from which have emerged more recently. High systolic 18.5 to 11.5 deaths per 1,000 people between blood pressure in particular has become the 1990 and 2016. Mortality rates in Nagaland leading risk factor for disease in India given its 2 direct role in contributing to related disorders much greater drivers of health loss than in the such as ischemic and hypertensive heart disease other three states, while smoking was revealed and stroke, as well as its less direct but still as the major behavioral driver. In Uttar Pradesh, substantial role in increasing diabetes and the environmental risks of poor sanitation, kidney disease. Low birth rate and babies born unsafe water for drinking and washing, and lack after abbreviated gestation periods are the of access to handwashing facilities were the most second leading risk factor, and account for a important drivers. Uttar Pradesh was also the only large proportion of neonatal disorders relative to one of the four states in which particulate matter lower respiratory and diarrheal infections which and household air pollution—again environmental were more prominent in 1990. India is presently factors—ranked among the top ten drivers of facing a “double burden.” Risk factors for non- disability adjusted life years. Each state thus communicable diseases are on the rise, but has a unique set of challenges to health, which communicable and childhood diseases are still a requires specific interventions targeting these major health concern. problems at the population level. The variation of age structures between Nutrition and dietary remain salient issues in Meghalaya, Nagaland, Uttar Pradesh, and all four states, as they do throughout India. Uttarakhand makes it necessary to standardize Maternal and childhood (including prenatal) are population age structures across the states foremost among these, and their longer-term to reveal how differently the epidemiological developmental repercussions for children remain transition is progressing in each. In Uttarakhand, unclear. Throughout India, these persist as leading metabolic risks, particularly high body mass causes of health loss in India, attributable for an index and total cholesterol were proportionately estimated 68 million disability adjusted life years Leading dietary risk factors for DALYs in India and the four states, both sexes, age-standardized, 2016 India Meghalaya Nagaland Uttar Pradesh Uttarakhand Low fruit 1 1 1 2 2 Low nuts and seeds 2 2 2 1 1 Low omega-3 3 4 4 3 3 Low vegetables 4 3 3 4 4 High sodium 5 5 5 6 5 Low fiber 6 7 7 5 7 Low whole grains 7 6 6 12 6 Low legumes 8 9 9 8 9 High trans fat 9 8 8 7 8 Low polyunsaturated fatty acids 10 11 11 10 10 Low calcium 11 10 10 9 11 Low milk 12 12 12 11 12 High processed meat 13 13 13 13 13 Highly sweetend beverages 14 14 14 14 14 3 in 2016. In Uttarakhand, the proportion of years cognitive development are likely to be significant. lost to premature death and disability attributable To generate a cohesive set of estimates of the to low birth rate and short pregnancies increased level and trends in cognitive development, and from 6.1 to 7.6 percent between 1990 and 2016. to quantify the impact of nutrition and other Nutrition-related risks at all ages also contributed key drivers in cognitive outcomes, the following to the number of disability adjusted life years work is anticipated: a comprehensive systematic that were attributable to cardiovascular diseases review; development of a standardized approach in 2016. Standardizing for age, 11 specific to measuring trends and levels in cognition; and dietary risks accounted for leading factors in the estimate the impact of nutrition and other risks four states – and in all four, diets low in fruits, on cognitive function. Another opportunity for vegetables, nuts, seeds, and omega-3 fatty acids further work is to provide rural-urban burden were among the leading risks among these. of disease and risk factors estimates for all While each state has a specific combination of states of India and the union territories. This is risk factors and health challenges, dietary and planned as part of Global Burden of Disease 2017 nutritional risk factors are common to all the study, and would include estimates of diarrheal states; national attention to these issues may diseases, nutritional diseases, and dietary and therefore lead to significant health gains across malnutrition-related risk factors in the burden of all age-groups. disease framework. Opportunities for further work Finally, the India State-Level Disease Burden Initiative is expanding the network of experts The subnational-level disease burden estimates in involved in the Initiative to identify further relevant India lay the groundwork for future study. The GBD data, benefit from the expert knowledge in India comparative risk assessment framework may be in the analysis and interpretation of findings used to provide an expansive quantitative view of and increasing dissemination efforts in India to the relationship between nutrition and cognition, inform policy. Continued work on analyzing rural as well as the impacts of broader determinants of versus urban trends and quantifying the losses health and nutrition in India. Persistent deficits in attributable to different risk factors can potentially cognitive development and skills can be caused establish the benchmarks for important health by poor health and inadequate nutrition early in policies. Fostering scientific and governmental life, leading to lifelong challenges for reasoning, collaboration can galvanize the utilization of employment, and overall well-being. In India, these results in health policy, informing state where the burden of malnutrition, diarrhea, and national priorities, and ultimately improving and other infectious diseases is high in children health of India’s population through targeted, under 5, these missed opportunities for full local, evidence-based decision-making. Partners SA FANSI Administered by: This results series highlights development results, operational innovations and lessons emerging from the South Asia Food and Nutrition Security Initiative (SAFANSI) of the World Bank South Asia region. Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.