This analysis found an association between state income inequality and levels of nutritional status, as measured by BMI, even after adjusting for a range of individual and state‐level covariates in India. The adverse contextual
effect of state income inequality is observed for the risk of being underweight as well as for each of the categories that characterise overnutrition (i.e.
pre‐overweight, overweight and obese). It is important to emphasise that what we report is a contextual effect of income inequality, after adjusting for individual‐level factors, including economic standard of living, which we know has a clear relationship to nutritional status (in that women of low socioeconomic status experience the greatest risk for underweight and those in high socioeconomic status experience the greatest risk for being pre‐overweight, overweight and obese)6,42,43,44
, a pattern also observed in this study. Thus, the context of inequality seems to accentuate
the income‐based disparities in consumption (reflected in people's BMI).
Why should income inequality be adversely associated with both
undernutrition and overnutrition? An insightful analogy can be drawn with the causes of famines. Famines, as we now understand, are caused not so much by a shortage of food as by the maldistribution of food.45
In a similar manner, the simultaneous presence of under‐ and overnutrition probably reflects the maldistribution of resources in food and as well other domains of critical importance to nutritional status. Thus, highly unequal states are characterised by the simultaneous existence of overconsumption by privileged groups and food insecurity among the poor. In addition to being an indicator of maldistributed resources, income inequality may also be a marker of a less generous, or inefficient, public distribution system, e.g. as a result of corruption.7
For instance, it has been shown that the non‐poor are more likely than the poor to use public systems designed to provide shelter, water, sanitation and sewerage, health care and food grains,46
suggesting that public distribution systems in many communities are poorly designed to meet the needs of the poor, a necessary condition for overcoming the burden of undernutrition. At the same time, it is likely that existing public distribution systems are vulnerable to manipulation by vested interests, a characteristic more likely to be present in states with high levels of income inequality and low social cohesion.
Indeed, there is evidence to suggest that one of the flagship programmes aimed at improving nutrition of children and mothers – the Integrated Child Development Scheme (ICDS) – is regressive in several ways.47
First, coverage of the programme is highest in states with the lowest levels of undernutrition. Second, coverage of the ICDS programme tends to be higher in states with high economic growth. Finally, in the poorer states, government budgetary allocations for the ICDS programme per undernourished child is lower. Indeed, poorer states also tend to spend only 65–75% of their allocation, suggesting poor governance. The regressive nature of this programme increased in the 1990s.47
Thus, it is possible that there may be other contextual features of high‐inequality states that make the goal of eliminating undernutrition difficult.
The fact that, on average, coverage of the ICDS programme tends to be greater in the richer states has led to the hypothesis that economic growth may eventually lead to a reduction in undernutrition through a trickle‐down mechanism. However, in our analysis we could find only partial support for this. For instance, although women in richer states were more likely to be overnourished, there was no evidence that in these states the risk for underweight was actually lower than in states with considerably lower levels of economic growth. In a previous study, it was reported that for women in richer states the risk of being underweight increased for those in the lowest quintile of standard of living and decreased for those in the highest quintile.6
This again suggest that the health dividends of aggregate economic development seem to accrue largely to better‐off sections of the population.
The following caveats should be borne in mind when considering our study findings. BMI was the only measure of nutritional status available. While a low level of BMI is likely to be a valid proxy for chronic energy deficiency in an individual, BMI does not adequately correlate with measures of body fat, which, for any value of BMI, may be higher in Indians than in other populations.48,49
Thus, for any given BMI, the risk for the consequences of obesity, such as diabetes and cardiovascular disease, may be greater among Indians than in the populations on which BMI standards were initially developed.50
These factors may limit the ability of our study to estimate the true burden of chronic diseases and mortality associated with undernutrition and overnutrition; however, in the Indian context, women's BMI may have particular relevance because of its impact on the health of their offspring. Women of low pre‐pregnancy BMI have lower‐birthweight babies,51
and the evidence that low birthweight and low maternal BMI are associated with increased risk of adulthood chronic disease among offspring is consistent and universal.52
Indeed, the coexistence of undernutrition and overnutrition in India also means that the consequences of maternal obesity – high birthweight and a higher risk of diabetes among offspring – will increasingly be seen.52
As Osmani and Sen point out,20
gender inequality can contribute to the intergenerational transmission of poor health through poor intrauterine and early life course exposures. It should also be noted that our findings relate to ever‐married women between the ages of 15 and 49, even though it has the advantage of being nationally representative. However, the patterns observed in this study with regards to the relationship between nutritional status and individual covariates (including socioeconomic position) is consistent with prior studies on women and
thus strengthening the general relevance of our findings.
In conclusion, our study has shown an association between state income inequality and the concurrent presence of risk of individual underweight and overweight. Focusing on overall economic equity – especially during phases of health and economic transition – is likely to address this dual burden.
What is already known on this subject
The double burden of undernutrition and overnutrition, which is characteristic of rapidly developing economies, is increasingly being recognised. However, the macroeconomic determinants of this double burden have to date not been systematically investigated.