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Trends and socioeconomic Socioeconomic

disparities in
disparities in undernutrition nutrition

among Muslim women in India:

evidence from the last two
decades (1998–2021) Received 1 May 2023
Revised 18 September 2023
Accepted 4 October 2023
Zeenat Hashmi and Ashish Singh
SJM School of Management, Indian Institute of Technology Bombay, Mumbai, India

Abstract
Purpose – A woman’s nutritional status significantly determines her overall well-being. The authors critically
examine the trends — including socioeconomic disparities — in undernutrition among Muslim women in India,
a notably socio-economically disadvantaged group. The authors also investigate trends and variations across
the dimensions of caste, place of residence (rural/urban), education, economic status and geographic regions.
Design/methodology/approach – The analysis leverages the nationally representative National Family
Health Surveys (NFHS) of India conducted between 1998 and 2021. The authors examined poor–rich ratios,
concentration indices, disparity ratios and predicted probabilities of being underweight (captured using Body
Mass Index).
Findings – From 1998 to 2021, there has been a decline in undernutrition prevalence among Muslim women.
However, stark socioeconomic variations persist. While the prevalence has decreased over time across all
socioeconomic groups, disparities — both within and between groups — remain significant and, in many
cases, have expanded. For certain socioeconomic subgroups (e.g. Muslim women with no formal education or
those in the Central and Northeast regions), the disparity doubled between 1998 and 2021. In regions like the
South, where undernutrition prevalence is low or has reduced, disparities remain significant and generally have
increased.
Originality/value – To the authors’ knowledge, the study is the first to provide a comprehensive examination
of the prevalence, trends and socioeconomic disparities in undernutrition among Muslim women in India over
the past two decades.
Peer review – The peer review history for this article is available at: https://publons.com/publon/10.1108/
IJSE-04-2023-0320
Keywords BMI, Concentration index, Disparity ratio, Health inequality, India, Muslim women, Poor-rich ratio,
Undernutrition, Underweight
Paper type Research paper

1. Introduction
Nutrition is the process of obtaining and using food essential for an individual’s survival and
growth. According to the World Health Organization (WHO), proper nutrition equips an
individual with resistance or immunity to various physical and mental health problems
(WHO, 2017). Undernutrition can arise from various factors, such as, biological (e.g., HIV,
AIDS, TB), behavioural (like mental disorders, insufficient knowledge sanitation) and socio-
cultural influences (including social customs and religious taboos) (Bhattacharya et al., 2019).

The authors are grateful to Anupam Agrawal and Apoorva Nambiar for helpful comments, suggestions
and proof reading. The views expressed in the paper are those of the authors and should not be
attributed to the Indian Institute of Technology Bombay, Mumbai, India.
International Journal of Social
Open data statement: In the interest of transparency, data sharing and reproducibility, the author(s) Economics
of this article have made the data underlying their research openly available. It can be accessed by © Emerald Publishing Limited
0306-8293
following the link here: https://www.iipsindia.ac.in/content/nfhs-project DOI 10.1108/IJSE-04-2023-0320
IJSE The WHO reports that around 45% of children and women in low-and-middle-income
countries succumb to causes related to undernutrition (Jakab, 2011). Among these nations,
India boasts remarkable economic growth record over the past two decades, establishing
itself as one of the fastest-growing economies worldwide. Yet, despite this economic progress,
it still lags in socio-demographic development, grappling with pervasive hunger and
malnutrition among both children and women (Ministry of Health and Family Welfare
MoHFW, Government of India, UNICEF and Population Council, 2019).

1.1 Nutritional status: the Indian national picture

In both India and the broader developing world, malnutrition—primarily undernutrition—
impacts individuals across all socioeconomic levels. The National Nutrition Monitoring Bureau
(NNMB) reports that approximately 46% of individuals nationally and between 28 and 70% at the
state level in India have inadequate calorie intake (National Nutrition Monitoring Bureau, 2017).
Despite numerous schemes, policies and programs aimed at alleviating hunger and providing food
for all, the underprivileged in India frequently struggle to feed their families and themselves. This
situation often translates to poorer health, educational and labour outcomes (Banerjee and Duflo,
2012). This problem is especially pronounced among the economically and socially disadvantaged
and vulnerable sections (Bhattacharya et al., 2019). Within these vulnerable sections, women are
often identified and acknowledged as particularly affected (Bellundagi et al., 2022). The pervasive
gender-based discrimination in India, spanning from the ancient to the current times, results in
numerous challenges for women, including in areas of education, occupation and nutrition
(Choudhary and Singh, 2018). Also, research on the interlinkages between child outcomes and
parental characteristics indicates that children’s outcomes, especially in education and health,
heavily rely on their mother’s educational and health status (Bellundagi et al., 2022).

1.2 Nutritional status, vulnerability lens and gender aspects: further exploration
Since gaining independence in 1947, the overall health and well-being of the Indian
population have generally improved. However, the nutritional status of adolescent girls,
women and children below five years of age remains a concern (Hazarika et al., 2012).
Women’s nutritional status significantly impacts the nutritional profile of a household, as
they have diverse roles that directly or indirectly influence the nutritional status of the entire
household (Chatterjee and Lambert, 1989). However, fulfilling these diverse roles often
negatively affects their own nutritional levels, as they prioritize the household’s nutritional
status over their own. The burden of inadequate nutrition within a household often falls on
women, as male members, often being the primary breadwinners, are given priority in
sustenance to ensure they remain fit for work (Agarwal and Pakrashi, 2020). Women of
reproductive age face additional nutritional vulnerabilities due to menstruation, pregnancy,
the post-natal period and breastfeeding. The negative effects of female nutritional
deficiencies include physical underdevelopment, high infant and maternal mortality rates
and a skewed sex ratio (Devine and Lawlis, 2019). Given this, assessing the nutritional status
of women is vital to understand their health and overall well-being in the Indian context.

1.3 Nutritional status, women and socio-religious consideration

Continuing with the discussion on the interaction between nutritional status and
socio-economically vulnerable sections in the Indian context, the Sachar Committee (Sachar,
2006) reported that the socioeconomic condition of Muslims (the largest religious minority
group in India) is deplorable. A vast majority of Muslims struggle to adequately access the
benefits of the fundamental and development rights guaranteed by the constitution. Within the
Muslim community, Muslim women are considered a “minority within a minority”. They lag
behind in important outcomes, like educational attainment and health, compared to women Socioeconomic
from other religious communities (Parveen, 2022). As per Kakwani et al. (1997) and Mistry disparities in
(2005), gender inequality in India is often associated with socio-cultural and religious factors;
it is not surprising, therefore, that Muslim women face pronounced demographic,
nutrition
socioeconomic and health disparities in the Indian context. Muslim women are not only
socially and economically deprived but also educationally disadvantaged (Parveen, 2022).
Unsurprisingly, the overall health of Muslim women is reported to be inferior compared to that
of women in other communities (Ohlan, 2020). Muslim women in the age group of 15–49 years,
which covers women of reproductive age, are particularly susceptible to the vicious cycle of
nutritional deficiencies, leading to worsened health outcomes and overall well-being (Hazarika
et al., 2012). Despite recent improvements, many Muslim women still face restrictions on
mobility, decision-making power and participation in public life (Tackett et al., 2018). Such
constraints impact their access to formal employment opportunities, which in turn affects their
educational, financial and health outcomes (Zajacova and Lawrence, 2018). Although the
nutritional status of majority of women in India has been studied, a comprehensive analysis of
the nutritional status of Muslim women in India is limited.
Within this context, one could also examine how religion and social factors, such as caste,
may affect the nutritional status of women by influencing dietary patterns: religiosity can have
a significant influence on dietary patterns through a combination of cultural, social, ethical and
theological factors. Religion has a multifaceted and complex relationship with health
behaviours via the patterns of dietary intake and physical exercises (Kim and Sobal, 2004).
Different religions sometimes establish specific guidelines and beliefs that dictate permitted
and prohibited foods, often providing guidelines on food preparation and consumption (Tan
et al., 2013). Religion has also been linked directly to nutrient intake, food choices and eating
practices due to factors like social support, networks and control (Kim and Sobal, 2004; Tan
et al., 2013). Moreover, religious teachings and scriptures may contain dietary practices and
guidelines. Adherents often learn about dietary behaviour from religious leaders, texts and
traditions, influencing their food choices (Ansari et al., 2017). Similarly, caste is associated with
the nutritional status of women through the availability, accessibility and confirmability of
cultural (and social) traditions related to food. Caste has been indicated as influencing the social
fabric and structure of Indian society, with “Scheduled Castes (SC)” (constitutionally identified
collection of castes) and “Scheduled Tribes (ST)” (constitutionally identified collection of tribes)
being the socially and historically disadvantaged, discriminated and excluded groups and sit at
the bottom of the social hierarchy (Deshpande, 2012; Mutatkar, 2005). Their history of
discrimination ranges from food access to the practice of untouchability, leading to
unfavourable economic, health and social outcomes (Deshpande, 2012; Mutatkar, 2005).
Similarly, “Other Backward Castes” (OBC) have been considered historically relatively
advantaged than SCs and STs but disadvantaged than the “Other” caste groups.
Considering the above, a study of the prevalence and trends, along with the socioeconomic
variations, of undernutrition of a discriminated gender within an overall marginalised
minority community becomes pertinent. We, therefore, in this paper make such an attempt.

2. Data and methods

2.1 Description of data
This study uses data from multiple rounds (1998–99, 2005–06, 2015–16 and 2019–21) of the
National Family Health Survey (NFHS), which is a nationally representative (covers 99% of
India’s population), repeated cross-sectional, micro-unit recorded household survey in
representative samples of households throughout India (Pathak and Singh, 2011; IIPS, 2022)
and is considered reliable in terms of sample size, survey design, coverage as well as socio-
economic-demographic variables of interest (e.g., caste, religion, gender, urban-rural residence,
IJSE wealth status) (Singh, 2012). It has detailed information on women, including anthropometric
measures like height and weight, collected through the household and woman’s questionnaires
(IIPS, 2022; Pathak and Singh, 2011). The use of NFHS 1998–99 (2), 2005–06 (3), 2015–16 (4) and
2019–21 (5) provides an opportunity to not only investigate the changes but also analyse the
improvements that have happened during the post-economic reform period in India. It is
important to note that the first round (1; 1992–93) of NFHS could not be included in the present
study due to the absence of data on height and weight for eligible women.
The estimates derived from the various NFHS rounds are comparable, as the rounds have
followed a comparable sampling design for selecting households and women for interviews
(Ram and Roy, 2004; IIPS, 2022). More than 90,000 households (and an eligible woman in the age
group of 15–49 years in each household) have been interviewed in each round of NFHS, and the
response rates have been consistently above 90% in the various rounds (Pathak and Singh,
2011; IIPS, 2022). Given the sufficiently large sample sizes and high response rates, it is possible
to conduct insightful analyses at the national and regional levels. As NFHS uses a multistage
sampling design, we have used appropriate weights (already given in the rounds of NFHS)
while generating the estimates presented in this study (IIPS ORCMacro, 1995, 2007; IIPS, 2022).

2.2 Measures, statistical methods and analysis of data

Our primary interest lies in evaluating nutritional status. Several measures can capture this,
broadly categorized into: (a) anthropometry, (b) biochemical assessment, (c) clinical
assessment and (d) dietary intake. Owing to its convenience, clarity, cost-effectiveness,
“low technology” usage, non-intrusive properties and objectivity, BMI is one the most used
anthropometric measures for the assessment of nutritional status (Duggan, 2010;
Bhattacharya et al., 2019; Budzy
nski and Szukay, 2022). Moreover, to predict outcomes of
low body mass, BMI has been suggested to be a primary index for nutritional assessment
(especially for individuals aged 14 and above) despite its limitations, as it is a better predictor
than body weight for measuring the proportion of fat mass relative to lean mass (Bechard
et al., 2016). Last but not the least, the NFHS data sets, which we have used for the analysis,
have consistent information only on anthropometrics for the whole period of 1998–2021,
limiting our choice of measures for the present study. It is important to highlight that the BMI
generally has a low precision as it does not distinguish between fat mass and lean mass, and it
measures excess weight rather than excess fat, which leads to low sensitivity as a marker for
higher values in the case of overweight and obese, whereas, a low BMI has better sensitivity
to be used as a single index of malnutrition (Budzy
nski and Szukay, 2022). As such, this study
predominantly employs BMI as an underweight (undernutrition) metric.
BMI is calculated as the ratio of weight (in kilograms) to the square of height (in meters).
As per WHO, the prevalence of undernourishment (undernutrition/underweight) is signified by
BMI<18.5, whereas the prevalence of severe undernutrition (underweight) is signified by
BMI<16 (WHO, 2017). Using BMI as the primary indicator/measure and referencing the
previously mentioned NFHS rounds from 1998–99, 2005–06, 2015–16 and 2019–21, we
examined the prevalence of underweight among Muslim women (ever married, aged 15–49)
across various geographic regions of India. We also examined trends and socioeconomic
variations, considering factors like the area of residence, caste, education and economic status,
specifically within the Muslim women community. Also, since pregnancy and childbirth lead to
drastic changes in women’s weight, we excluded women who were pregnant or had given birth
within the two months preceding the survey, aligning with established literature on assessing
women’s nutritional status (Yaya and Ghose, 2020). Our final sample for the analysis is
comprised of 81,203 (NFHS 2), 85,772 (NFHS 3), 485,635 (NFHS 4) and 504,744 (NFHS 5) women
from distinct regions of India, namely East, West, Central, North, South and Northeast — based
on NFHS’s own classification (IIPS, 2022).
 To analyze the socioeconomic trends in prevalence of underweight among women, we Socioeconomic
employed a range of methods: cross-tabulations, Poor-Rich (PR) ratios, disparity ratios, disparities in
concentration indices and predicted probability of being underweight. The PR ratio is
specifically the ratio of the prevalence percentage of underweight women (captured using
nutrition
BMI<18.5) in the poorest wealth quintile to the prevalence percentage of underweight women
in the richest wealth quintile. This ratio has been used in the existing literature to summarize
economic disparity in the distribution of undernutrition (Pathak and Singh, 2011; they have
used it in the context of children). It is a simple and commonly used measure to examine
socioeconomic disparities in health, education and similar outcomes. A PR ratio of 1 indicates
that undernutrition is equally prevalent among both the poorest and richest groups, whereas
a PR ratio greater than 1 indicates a higher likelihood of the poorest suffering from
undernutrition. Disparity ratio is calculated as the ratio of the highest to the lowest
underweight prevalence; for example, for geographic regions, the disparity ratio will be
derived (as a ratio) from the region with the highest prevalence of underweight compared to
the region with the lowest (a comprehensive detailing of all the methods and measures,
including their respective formulas/equations, has been provided in the supplementary
material S1).
The concentration index is a widely acceptable measure frequently employed to capture
socioeconomic inequalities in health (Wagstaff and van Doorslaer, 2004; Pathak and Singh,
2011). It is derived from the concentration curve (Wagstaff and van Doorslaer, 2004), which
measures health inequalities (O’Donnell et al., 2008). The curve plots the cumulative
proportion of women, ranked by socioeconomic status “x”, against the cumulative proportion
of underweight women “y”. In our analysis, the concentration index captures how the
prevalence of underweight varies across the distribution of wealth (using wealth quintiles
provided in the surveys). The concentration index ranges between 1 and
1; transitioning
from 1 to
1 signifies increasing inequality.
Further, we estimated the predicted probabilities of being underweight across different
socioeconomic categories. We conducted the analysis at the all-India level and across
different geographic regions of India to account for the regional diversity.

3. Results
Table 1 shows the percentage distribution of Indian women aged 15–49 years based on
their socioeconomic characteristics like religion (captured as Muslim, Hindu, Christian,
Sikh, Buddhist, Jain and others), caste (captured as SC/ST; OBC and Others), place of
residence (captured as urban and rural), education (captured as no formal education,
completed primary [5 years], completed secondary [10 years] and completed higher
secondary [12 years]), wealth quintiles and geographic regions (hereafter, referred as
regions; details provided earlier). As illustrated in the table, Muslim (the largest minority
religion in India) women constitute about 13% of the total women population in the 15–49
age group. Their proportion increased from 11.7% to 12.6% during the study period.
A significant observation from this table is the marked increase in the education levels of
women in India.

3.1 Trends in undernutrition among women in India

Though the primary objective of our study is to examine and investigate the trends (and the
associated socioeconomic disparities) in undernutrition among Muslim women, we have also
documented the trends in undernutrition among all women in India (in Supplementary
material S2, due to space constraints). The percentage prevalence of undernutrition among
women in India has declined from 36.3% in 1998 to about 14% in 2021. The prevalence has
IJSE Characteristics NFHS-2 NFHS-3 NFHS-4 NFHS-5

Religion
Hindu 82.30 81.94 81.67 82.41
Muslim 11.75 12.49 12.8 12.63
Christian 2.68 2.28 2.30 2.27
Sikh 1.68 1.74 1.63 1.50
Buddhist 0.83 0.80 0.93 0.63
Jain 0.38 0.28 0.19 0.18
Others 0.39 0.46 0.50 0.37
Caste
SC/ST 27.05 27.05 29.56 31.16
OBC 33.44 39.74 43.55 42.91
Others 39.51 33.21 26.89 25.93
Place of residence
Urban 26.71 30.62 33.49 31.23
Rural 73.29 69.38 66.51 68.77
Education
No education 52.59 47.86 34.59 29.12
Primary 17.38 15.82 14.64 14.42
Secondary 22.24 30.78 41.4 44.72
Higher 7.79 5.55 9.37 11.74
Wealth quintiles
Poorest 19.07 18.47 18.06 18.85
Poorer 19.46 19.90 19.84 20.28
Middle 20.29 20.46 20.73 20.88
Richer 20.29 20.52 21.16 20.81
richest 20.89 20.65 20.20 19.18
Region
North 12.65 13.09 13.06 13.5
Central 18.99 22.28 22.07 22.8
Table 1. East 23.03 23.27 22.83 23.73
Percentage
West 15.28 14.65 14.69 14.43
distribution of socio-
economic South 26.57 23.11 23.89 21.77
characteristics of North East 3.48 3.60 3.46 3.77
Women in India based Note(s): SC/ST5Scheduled castes and scheduled tribes; OBC5Other backward castes
on NFHS, (1998–2021) Source(s): Author’s calculation based on NFHS-2, NFHS-3, NFHS-4 and NFHS-5 data

decreased among women of all religions, falling to below 10% among Christians, Jains and
Sikhs as well as of all caste groups. Trends related to women’s education show that the gap in
the prevalence of undernutrition by women’s education has reduced over the study period.
The disparity in the prevalence of undernutrition by place of residence (rural/urban) is
significant, with the prevalence in rural areas being more than double that of urban areas.
Further, the prevalence in the poorest wealth quintile (24%) is almost five times higher than
that in the richest quintile (5%). Moreover, the Central and Eastern regions, comprising the
poorest (socioeconomically) states of India, have a significantly higher prevalence of
undernutrition than that in the Southern region.
The prevalence of undernutrition among Indian women has been shown comprehensively
(for all the states within the six regions under study) in Supplementary material S3 (a to d) for
the 1998 to 2021 period. The figures depict the stark inter-state variations in undernutrition
among women in India.
3.2 Trends in undernutrition among Muslim women in India Socioeconomic
The various trends in the prevalence of undernutrition among Muslim women across disparities in
different socioeconomic characteristics are presented in Table 2. Among Muslim women, the
prevalence has decreased from 34.2% in 1998 to 10.8% in 2021. Though the prevalence of
nutrition
undernutrition has reduced substantially over the study period, it is relatively higher in the
SC/ST community (14%), in rural areas (13%) and among women with no formal education
(13%). It is also substantially higher in the poorest quintile (19%) than in the richest quintile
(5%). Also, the prevalence is relatively higher in the central and eastern regions.
Supplementary material S4 (a to d) shows the distribution of the percentage prevalence of
underweight among Muslim women for all the states of India for the study period.
The supplementary figures depict the pronounced inter-state variations in undernutrition
among Muslim women; for example, Fig. S4(d) indicates that on the one hand, there are states
like Tamil Nadu where the prevalence is between 0 and 4%, whereas, on the other hand, there
are states like Bihar and Jharkhand where the prevalence of underweight is up to 19%.

3.3 Trends and differentials in undernutrition among Muslim women by socioeconomic

status
Economic disparities in undernutrition indicate the degree to which undernutrition rates
differ between more and less economically advantaged groups (Pathak and Singh, 2011).

Socio-economic characteristics NFHS-2 NFHS-3 NFHS-4 NFHS-5

Caste
SC/ST 34.59 37.55 19.97 14.02
OBC 32.76 29.45 15.11 10.58
Others 34.59 33.36 16.43 10.67
Place of residence
Urban 25.16 20.66 10.41 7.37
Rural 38.88 38.85 20.55 13.02
Education
No education 40.18 38.32 19.69 12.66
Primary 31.78 29.48 16.48 10.6
Secondary 23.24 22.7 13.05 10.05
Higher 18.94 8.58 8.39 6.44
Wealth quintiles
Poorest 50.46 49.71 28.95 18.61
Poorer 46.11 45.18 22.52 13.15
Middle 36.49 32.73 15.08 10.34
Richer 27.54 22.39 9.83 6.70
Richest 16.56 11.14 6.37 4.97
Regions
North 28.54 26.77 12.2 6.84
Central 37.41 34.10 16.81 10.83 Table 2.
East 46.36 42.97 20.98 13.29 Percentage prevalence
West 27.82 22.87 14.28 11.08 of undernutrition
(captured by
South 22.34 17.04 7.67 6.51 underweight) among
North East 33.43 44.89 25.30 14.54 Muslim women in India
All 34.16 32.14 15.99 10.77 by socio-economic
Note(s): SC/ST5Scheduled castes and scheduled tribes; OBC5Other backward castes characteristics,
Source(s): Author’s calculation based on NFHS-2, NFHS-3, NFHS-4 and NFHS-5 data 1998–2021
IJSE We have examined and measured the economic disparity in undernutrition among Muslim
women using the PR ratio and the concentration index. Additionally, we have used the
disparity ratio to capture the socioeconomic differentials.
The PR ratio among Muslim women is presented in Table 3 (Panel A). The PR ratio has
increased substantially (from 3 to 3.7) for Muslim women as a whole, indicating that the
economic inequalities in undernutrition have risen considerably from 1998 to 2021. Within
the Muslim women, if we observe by caste groups, the ratio is the highest for the OBCs.
In 2021, it stands at 4.7, meaning that within the Muslim women of the OBC caste group, the
prevalence of undernutrition in the poorest quintile is 4.7 times than that in the richest
quintile. This discrepancy has grown both in rural and urban areas. Also, in all educational
categories, it has increased considerably. It is worth noting that it has more than doubled
during the study period among Muslim women with no formal education. Observations by
geographic regions show a decrease in the Southern and the Western regions but an increase
for the other four regions. The increase is the highest for the Central and the North-east
regions, where it has more than doubled (from 2 to 5 and 2.7 to 6, respectively) followed by the
Eastern region during the study period. Another important finding from the table is that even
in regions where the prevalence of undernutrition is low, the PR ratio is high. For example, the
Southern region has one of the lowest prevalence (6.5% in 2021) but a high PR ratio (4.2 in
2021), indicating high economic inequality.
Another approach used to examine the economic disparities in undernutrition is the
concentration index, which is presented in Table 3 (Panel B). The table shows that for
Muslim women as overall, the economic inequalities in undernutrition have increased from

0.2 in 1998 to
0.25 in 2021. Among Muslim women, when observing by caste groups, it is
evident that economic disparities have increased across all caste groups. This growth in
disparities is seen both in rural and urban areas and has expanded across almost all
education levels of women except for those who have completed higher secondary
schooling. But for these women, the concentration index is less than zero, indicating high
inequality in undernutrition. Analysis by geographical regions suggests that, except for
Southern and Western regions, economic inequalities in undernutrition have risen in all
other regions. A point worth noting here is that even in these two regions, the concentration
index is less than zero, indicating substantial inequality. The sharpest rise in economic
disparities can be observed in the Central and Eastern regions, where it has more than
doubled during the study period.
In addition to the PR ratio and concentration index, we have employed Disparity ratios.
These are determined as the ratio of highest underweight prevalence to the lowest
underweight prevalence. There is a difference between how PR ratio and concentration
index have been operationalized and how the disparity ratio has been estimated. For
example, if we consider the division of Muslim women into caste groups, we calculate PR
ratios and concentration indices for each caste category, namely SC/ST, OBC and Others.
However, the disparity ratio is computed as a ratio of the prevalence of undernutrition in
the sub-group with the highest prevalence to the prevalence in the subgroup with the
lowest prevalence. In a sense, while the PR ratio and concentration indices capture
disparities within each subgroup of a particular category, the disparity ratio encapsulates
disparities between subgroups within that category. The results are presented in
Supplementary Material (table) S5 (due to lack of space). In 2021, the peak disparity ratio
was at 3.75, observed in the case of wealth. The socioeconomic disparity in undernutrition
has increased during the study period in all cases except when we look into variation in
undernutrition by education (where also it is high). The most pronounced growth in
disparity over the study period is observed when considering the distribution by caste
groups, with an increase of almost 25%. The second highest increase in disparity is by
wealth quintiles, where the increase is approximately 23%.
Characteristics NFHS-2 NFHS-3 NFHS-4 NFHS-5
Socioeconomic
disparities in
Panel A. Trends in economic disparities based on Poor-Rich ratios nutrition
Overall 3.04 4.46 4.55 3.75
Caste
SC/ST 2.10 3.10 2.78 2.07
OBC 2.83 3.61 4.86 4.72
Others 3.18 4.94 4.39 3.27
Place of residence
Urban 3.49 4.17 3.91 3.69
Rural 3.09 3.85 3.71 3.56
Education
No education 2.52 2.89 3.94 5.14
Primary 2.78 4.82 5.85 3.67
Secondary 2.23 5.02 4.50 3.74
Higher – – 2.37 2.65
Region
North 2.03 2.60 2.91 2.09
Central 2.04 3.75 3.93 4.99
East 2.73 4.52 5.51 4.86
West 3.77 5.18 3.82 2.11
South 4.94 4.97 2.67 4.20
North East 2.70 9.57 10.87 5.95
Panel B. Trends in economic disparities based on Concentration Index
Overall
0.201
0.241
0.279
0.248
(0.000) (0.000) (0.000) (0.000)
Caste
SC/ST
0.108
0.183
0.177
0.2
(0.000) (0.000) (0.000) (0.000)
OBC
0.206
0.21
0.297
0.282
(0.000) (0.000) (0.000) (0.000)
Others
0.203
0.255
0.268
0.225
(0.000) (0.000) (0.000) (0.000)
Place of residence
Urban
0.189
0.239
0.243
0.201
(0.000) (0.000) (0.000) (0.000)
Rural
0.153
0.162
0.196
0.19
(0.000) (0.000) (0.000) (0.000)
Education
No education
0.136
0.154
0.224
0.223
(0.000) (0.000) (0.000) (0.000)
Primary
0.191
0.231
0.257
0.212
(0.000) (0.000) (0.000) (0.000)
Secondary
0.212
0.307
0.277
0.252 Table 3.
(0.000) (0.000) (0.000) (0.000) Trends in economic
Higher
0.131
0.147
0.153
0.122 disparities based on
(0.003) (0.018) (0.000) (0.000) Poor-Rich (PR) ratios
and Concentration
Region Index with respect to
North
0.138
0.177
0.202
0.172 undernutrition (BMI
(0.000) (0.000) (0.000) (0.000) <18.5) among Muslim
women, India,
(continued ) 1998–2021
IJSE Characteristics NFHS-2 NFHS-3 NFHS-4 NFHS-5

Central
0.119
0.186
0.241
0.287

(0.000) (0.000) (0.000) (0.000)
East
0.091
0.127
0.186
0.185
(0.000) (0.000) (0.000) (0.000)
West
0.213
0.192
0.2
0.135
(0.000) (0.000) (0.000) (0.000)
South
0.270
0.256
0.219
0.253
(0.000) (0.000) (0.000) (0.000)
North East
0.118
0.137
0.179
0.15
(0.000) (0.000) (0.000) (0.000)
Note(s): (i) SC/ST5Scheduled caste and scheduled tribe; OBC5Other backward classes; (ii) p-values in
parentheses; (iii) the distribution of “higher education” category Muslim women into wealth quintiles was
leading to very small number of observations in the quintiles in NFHS 2 and NFHS-3, so PR ratios could not be
calculated for these cases
Table 3. Source(s): Author’s calculation based on NFHS-2, NFHS-3, NFHS-4 and NFHS-5 data using STATA

3.4 Predicted probability of Muslim women being underweight

Table 4 presents the predicted probabilities of Muslim women being underweight
(undernutrition) based on different socioeconomic characteristics. The predicted
probabilities of being underweight have been estimated using binary logistic regression of
being underweight on socioeconomic characteristics including caste, place of residence,
education, the wealth quintile a woman belongs and geographic region (details provided
earlier).
The findings presented in the table underscore the significant socioeconomic disparities in
the likelihood of Muslim women being underweight (or suffering from undernutrition). For
example, in 2021, Muslim women belonging to the “OBC” caste group have a 11.5% chance of
being underweight compared to 9.1% in the “Others” group. Place of residence (rural/urban)
also significantly affects the chances of being underweight, with the probability being higher
in rural areas compared to that in the urban areas. Similarly, the likelihood of being
underweight over the years is consistently higher in lower educational categories compared
to that in the higher ones; however, the gap is narrowing. One of the most pronounced
disparities in chances of being underweight is observed in the case of wealth. For example, in
2021, Muslim women in the poorest wealth quintile have a 16.5% chance of being
underweight compared to 4.7% for those in the richest quintile. Moreover, Muslim women
belonging to the region of East and Central have substantially higher chances of being
underweight than those belonging to the regions of North and South. One positive thing is
that the predicted probability of being underweight has reduced significantly during the
1998–2021 period for all socioeconomic groups, including those based on geographic regions.

4. Conclusions and discussion

One of the most fundamental physiological needs of humans is food, and one of the targets of
the Sustainable Development Goals (SDGs, 2030-goal 2) is eliminating hunger. To achieve
holistic socioeconomic progress, contribution of all sections of society by utilizing the full
potential, which depends upon the nutrition (among other factors) of all individuals, is
required (Cresp
ı-Llor
ens et al., 2021). Seen in this context, it is disconcerting that India, despite
witnessing impressive economic growth in the past three decades, continues to grapple with
the problem of undernutrition, specifically among women and children. Within women and
children, there are socioeconomic subgroups where the problem of undernutrition is more
 NFHS-2 NFHS-3 NFHS-4 NFHS-5
Socioeconomic
disparities in
Caste nutrition
SC/ST 0.295 0.257 0.167 0.093
(0.000) (0.000) (0.000) (0.000)
OBC 0.313 0.265 0.174 0.115
(0.000) (0.689) (0.24) (0.000)
others 0.304 0.267 0.145 0.091
(0.000) (0.612) (0.000) (0.724)
Place of residence
Urban 0.302 0.240 0.139 0.088
(0.000) (0.000) (0.000) (0.000)
Rural 0.313 0.287 0.167 0.105
(0.000) (0.000) (0.000) (0.000)
Education
No education 0.315 0.268 0.156 0.098
(0.000) (0.000) (0.000) (0.000)
Primary 0.303 0.254 0.161 0.095
(0.000) (0.241) (0.234) (0.393)
Secondary 0.278 0.274 0.161 0.105
(0.000) (0.602) (0.116) (0.012)
Higher 0.273 0.186 0.149 0.095
(0.000) (0.007) (0.49) (0.732)
Wealth quintiles
Poorest 0.454 0.427 0.256 0.165
(0.000) (0.000) (0.000) (0.000)
Poorer 0.413 0.387 0.201 0.12
(0.000) (0.034) (0.000) (0.000)
Middle 0.353 0.286 0.139 0.09
(0.000) (0.000) (0.000) (0.000)
Richer 0.257 0.227 0.107 0.063
(0.000) (0.000) (0.000) (0.000)
Richest 0.163 0.117 0.074 0.047
(0.000) (0.000) (0.000) (0.000)
Region
North 0.260 0.228 0.114 0.051
(0.000) (0.000) (0.000) (0.000)
Central 0.374 0.306 0.171 0.11
(0.000) (0.000) (0.000) (0.000)
East 0.357 0.298 0.182 0.122
(0.000) (0.000) (0.000) (0.000)
West 0.340 0.306 0.194 0.167
(0.000) (0.000) (0.000) (0.000)
South 0.256 0.189 0.112 0.089
(0.000) (0.005) (0.611) (0.000)
North East 0.290 0.285 0.189 0.108 Table 4.
(0.000) (0.000) (0.000) (0.000) Predicted probability
Note(s): (i) SC/ST5Scheduled caste and scheduled tribe; OBC5Other backward caste; (ii) p-value in of being underweight
parentheses among Muslim women
Source(s): Author’s calculation based on NFHS-2, NFHS-3, NFHS-4 and NFHS-5 data using STATA in India, 1998–2021

severe compared to others. Muslim women who are relatively marginalized and vulnerable
within the minority community in India form one such group. Among Muslim women, there
are stark socioeconomic variations in undernutrition. The present study, therefore, fills an
IJSE important research gap and is perhaps the first to comprehensively explore and examine the
nutritional status of Muslim women. It not only addresses this concern on a macro and
regional level within India but also delves into the variations of nutritional status across
different socioeconomic dimensions, while also capturing its evolution over time.
The study highlights a consistent decline in the prevalence of undernutrition among
women from 1998 to 2021. The literature has attributed this decline to various reasons like
improved awareness, empowerment and education among women (Zajacova and
Lawrence, 2018), improvement in Water, Sanitation and Hygiene practices (Kumar and
Mohanty, 2023), improved access to healthcare and the impact of nutrition-specific
interventions (Joumard and Kumar, 2015; Ahmad et al., 2023). The role of government
initiatives and policies in the reduction of the prevalence of undernutrition among women
of reproductive age in India is also documented and is described below: Integrated Child
Development Services (ICDS) have been found to have played one of the significant roles in
improving the nutritional status and overall development of women and children by
providing supplementary nutrition, immunization, health check-ups and pre-school
education to pregnant and lactating women (Kapil, 2002). Also, the National Health
Mission (NHM) has been encompassing various initiatives aimed at improving maternal
and child health, leading to decreased malnutrition over the years (Vastav Irava et al., 2022).
Further, the Janani Suraksha Yojana, a component of NHM, has been providing financial
assistance to pregnant women for institutional delivery (Vellakkal et al., 2017), thereby
encouraging better access to healthcare during pregnancy and childbirth, leading to better
nutritional outcomes (Kumar, 2021). Moreover, the Pradhan Mantri Matru Vandana Yojana
(PMMVY) is a maternity benefit program that provides financial support and cash
incentives to pregnant and lactating mothers to improve the health and nutrition of
pregnant women and their children (Government of India, 2017). In addition, the Rajiv
Gandhi Scheme for Empowerment of Adolescent Girls (SABLA) focuses on empowering
adolescent girls through various interventions, including education, health check-ups,
nutrition and life skills training (Meenakshisundareswari, 2020), thereby resulting in
improved nutritional status and overall well-being of adolescent girls, which has a positive
impact on their future health as well (Banseria et al., 2019). Furthermore, the National Food
Security Act (NFSA) does not exclusively target women, but has made a substantial
contribution by providing subsidized food grains to eligible households, ensuring better
access to nutritious food for vulnerable populations, including women (Varadharajan et al.,
2014). Last but not the least, the Anaemia Mukt Bharat initiative focuses on preventing and
controlling anaemia through awareness campaigns, iron and folic acid supplementation
and improving dietary practices among women, thereby leading to reduced underweight
prevalence (Ahmad et al., 2023).
An important finding of the study is that though the prevalence of undernutrition among
Muslim women has decreased from 34% in 1998 to 11% in 2021, the socioeconomic
disparities still remain very high and, in some cases, have increased over time. For example,
there are huge variations in the prevalence of undernutrition based on caste, educational
status, geographic region, place of residence and wealth. The prevalence of undernutrition
among the SC/ST is 4% higher than the prevalence in the “others” category. The prevalence
in rural areas is almost double than that in urban areas. Women without formal schooling
have a substantially higher prevalence (almost twice) than women who have at least
completed higher secondary schooling. The prevalence is nearly four times in the poorest
quintile compared to that in the richest quintile. Also, the prevalence is relatively higher in the
Central and the Eastern regions compared to the Southern and the Western regions. Further,
results based on concentration indices indicate that, barring the Southern and the Western
regions, the socioeconomic inequalities in the prevalence of undernutrition have substantially
increased in all other regions during 1998–2021. Moreover, the findings based on disparity
ratios also indicate significant socioeconomic disparities and an increase (in general) in Socioeconomic
disparities in undernutrition over time. Finally, even for the regions where the prevalence of disparities in
undernutrition is low, the socioeconomic disparity is high. For example, the Southern region
has one of the lowest prevalence (6.5% in 2021) but a high poor–rich ratio (4.2 in 2021), which
nutrition
means that the people belonging to the poorest quintile have more than four times the
prevalence of undernutrition compared to that in the richest quintile.
The results of our study are aligned with the results of existing scholarship. For example,
findings like regions (such as, the South) where the prevalence of undernutrition is low, the
disparity is high, or the prevalence has decreased over time, but the disparities have increased
are in line with that in Pathak and Singh (2011). They used the same dataset (but for children)
and found that socioeconomic inequalities were high among regions (and states) even where
the prevalence of undernutrition was low. This implies (as noted by Pathak and Singh, 2011
and equally relevant here) that regions or states that have achieved substantial reduction in
undernutrition among populations have not been as successful in reducing socioeconomic
disparity in undernutrition over time.
Our findings may guide/inform multiple health policy lessons. For example, as noted by
Pathak and Singh (2011, p. 584), any unidimensional health policy that focuses solely on
reducing average undernutrition at the cost of overlooking the socioeconomic distribution of
undernutrition might further worsen the disproportionate burden of undernutrition among
the poor and the marginalized; this might deepen the poor-rich divide in nutrition besides
destabilizing the efforts to reduce average undernutrition rates in India. The Government of
India has improved the focus on women and child nutrition as well as health care policies and
programs (such as ICDS, NHM, PMMVY etc.), which are likely to further bring down the
average prevalence of undernutrition, but there is ample scholarship indicating that there are
huge socioeconomic variations in access to these programs (such as ICDS) (Gragnolati et al.,
2005; Pathak and Singh, 2011; Bango and Ghosh, 2022). Moreover, there is variation across
the states in terms of focus, utilization and budgetary allocations to tackle the problem of
undernutrition, which has been identified as one of the major factors behind the stark inter-
state/inter-regional variation in nutritional status of women and children (Dasgupta et al.,
2005; Pathak and Singh, 2011; Government of India, 2023). Therefore, policies and programs
should also focus on reducing socioeconomic inequalities in women’s undernutrition in
addition to reducing the average prevalence rate of undernutrition.
Though our study has multiple strengths in terms of, for example, novelty, data from
reliable nationally representative surveys, use of multiple widely acceptable and appropriate
measures (results based on whom are coherent) and results consistent with existing literature,
it also has a few limitations. First, it is inadequate to demonstrate a causal relationship
between various socioeconomic characteristics and instances of undernutrition. However,
such inadequacy is common in studies based on a macro picture and cross-sectional
(or repeated cross-sections but not panel) data sets. A second concern is related to the use of
BMI as a measure to capture undernutrition because BMI is calculated in the same way for
adults, children and adolescents, without accounting for age and gender-specific growth
patterns, which might lead to somewhat biased assessments in children and adults where
body composition changes differently over time and by gender. However, since in the present
study, only women of the age group 15–49 have been studied, the extent of such bias is likely
to be low. One more limitation of BMI is that it fails to capture the body fat distribution, which
can be an important factor in determining health risks; the disease outcomes are based on
essential markers of malnutrition, such as, lean body mass and fat body mass, which are not
differentiated in the measurement of BMI (Aune et al., 2016). While other anthropometric
measures are used alongside BMI, such as arm circumference, a body shape index (ABSI),
conicity index, waist-hip ratio, waist circumference (WC), etc., but due to the unavailability of
data, we could not use them in the present study.
IJSE Last but not the least, there lies a need to further study the mediating factors that have the
potential to reduce the prevalence of undernutrition among women in India to guide the
policymakers in developing appropriate and relevant policies and programs. In future, this
agenda can be taken forward in terms of examining the specific contribution of each and
every socioeconomic characteristic/factor in reducing (or even increasing) the prevalence of
undernutrition among women over time in India.

References
Agarwal, C.L. and Pakrashi, D. (2020), “He has gone to a better place but she has not: health status of
Hindus widows in India”, The Journal of Development Studies, Vol. 57 No. 5, pp. 750-771.
Ahmad, K., Singh, J., Singh, R.A., Saxena, A., Varghese, M., Ghosh, S., Roy, S., Yadav, K., Joe, W. and
Patel, N. (2023), “Public health supply chain for iron and folic acid supplementation in India:
status, bottlenecks and an agenda for corrective action under Anemia Mukt Bharat strategy”,
PLoS ONE, Vol. 18 No. 2, pp. 1-18.
Ansari, S., Soltero, E.G., Lorenzo, E. and Lee, R.E. (2017), “The impact of religiosity on dietary habits
and physical activity in minority women participating in the Health is Power study”, Preventive
Medicine Reports, Vol. 5, pp. 210-213.
Aune, D., Sen, A., Prasad, M., Norat, T., Janszky, I., Tonstad, S., Romundstad, P. and Vatten, L.J. (2016),
“BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230
cohort studies with 3.74 million deaths among 30.3 million participants”, BMJ, Vol. 353 No. 6, pp. 6-8.
Banerjee, A. and Duflo, E. (2012), Poor Economics, Public Affairs, New York.
Bango, M. and Ghosh, S. (2022), “Social and regional disparities in utilization of maternal and child
healthcare services in India: a study of the post-national health mission period”, Frontiers in
Pediatrics, Vol. 10, 895033.
Banseria, R.B., Saroshe, S.S. and Dixit, S.P. (2019), “Evaluation of rajiv gandhi scheme for
empowerment of adolescent girls (RGSEAG)–‘SABLA’ in Indore district of Madhya Pradesh”,
Indian Journal of Community Health, Vol. 31 No. 1, pp. 30-35.
Bechard, L.J., Duggan, C., Touger-Decker, R., Parrott, J.S., Rothpletz-Puglia, P., Byham-Gray, L.,
Heyland, D. and Mehta, N.M. (2016), “Nutritional status based on body mass index is associated
with morbidity and mortality in mechanically ventilated critically ill children in the PICU”,
Critical Care Medicine, Vol. 44 No. 8, pp. 1530-1537.
Bellundagi, V., Umesh, K.B., Ashwini, B.C. and Hamsa, K.R. (2022), “Prevalence of malnutrition among
women and adolescent girls: impact of urbanization in rural–urban interface of Bangalore”,
British Food Journal, Vol. 124 No. 12, pp. 4200-4218.
Bhattacharya, A., Pal, B., Mukherjee, S. and Roy, S.K. (2019), “Assessment of nutritional status using
anthropometric variables by multivariate analysis”, BMC Public Health, Vol. 19 No. 1, pp. 9-11.
nski, J. and Szukay, B. (2022), “BMI as a biomarker in patients’ nutritional assessment”, in Patel,
Budzy

V.B. and Preedy, V.R. (Eds), Biomarkers in Nutrition. Biomarkers in Disease: Methods,
Discoveries and Applications, Springer, Cham, pp. 1-35.
Chatterjee, M. and Lambert, J. (1989), “Women and nutrition: reflections from India and Pakistan”,
Food and Nutrition Bulletin, Vol. 11 No. 4, pp. 13-28.
Choudhary, A. and Singh, A. (2018), “Effect of intergenerational educational mobility on health of
Indian women”, PLoS ONE, Vol. 13 No. 9, pp. 1-16.
Cresp
ı-Llor
ens, N., Hern
andez-Aguado, I. and Chilet-Rosell, E. (2021), “Have policies tackled gender
inequalities in health? A scoping review”, International Journal of Environmental Research
Public Health, Vol. 18 No. 1, p. 327.
Dasgupta, M., Lokshin, M., Gragnolati, M. and Ivaschenko, O. (2005), Improving Child Nutrition
Outcomes in India: Can the Integrated Child Development Services Program Be More Effective,
World Bank, Washington DC.
Deshpande, A. (2012), The Grammar of Caste: Economic Discrimination in Contemporary India, OUP, Socioeconomic
New Delhi.
disparities in
Devine, A. and Lawlis, T. (2019), “Nutrition and vulnerable groups”, Nutrients, Vol. 11 No. 5, p. 1066.
nutrition
Duggan, M.B. (2010), “Anthropometry as a tool for measuring malnutrition: impact of the new WHO
growth standards and reference”, Annals of Tropical Paediatrics, Vol. 30 No. 1, pp. 1-17.
Government of India (2017), Pradhan Mantri Matru Vandana Yojana (PMMVY), Ministry of Women
and Child Development Government of India, New Delhi.
Government of India (2023), Health Sector Financing by Centre and States/Uts in India, National Health
Accounts Cell, Ministry of Health & Family Welfare, New Delhi.
Gragnolati, M., Shekar, M., Dasgupta, M., Bredenkamp, C. and Lee, Y. (2005), “India’s undernourished
children: a call for reform and action”, Discussion paper, World Bank, Washington DC.
Hazarika, J., Saikia, I. and Hazarika, P.J. (2012), “Risk factors of undernutrition among women in the
reproductive age group of India: an evidence from NFHS-3”, Journal of Scientific Research, Vol. 7
No. 1, pp. 5-11.
IIPS (2022), National Family Health Survey - 5 2019-21, International Institute for Population Sciences,
Ministry of Health and Family Welfare, New Delhi.
IIPS ORC Macro (1995), National Family Health Survey (NFHS - 1), 1992e93: India. International
Institute for Population Sciences, Mumbai.
IIPS ORC Macro (2007), National Family Health Survey (NFHS - 3), 2005e06: India, Vol. I. International
Institute for Population Sciences, Mumbai.
Irava, V., Malhotra, S. and Kapur, A. (2022), Summary and Analysis Highlights, Vol. 13 No. 5, pp. 1-12.
Jakab, Z. (2011), Constitution of WHO, Official Records of WHO, Geneva.
Joumard, I. and Kumar, A. (2015), Improving Health Outcomes and Health Care in India, OECD,
Washington DC.
Kakwani, N., Wagstaff, A. and Van Doorslaer, E. (1997), “Socioeconomic inequalities in health: measurement,
computation, and statistical inference”, Journal of Econometrics, Vol. 77 No. 1, pp. 87-103.
Kapil, U. (2002), “Integrated Child Development Services (ICDS) scheme: a program for holistic
development of children in India”, Indian Journal of Pediatrics, Vol. 69 No. 7, pp. 597-601.
Kim, K.H. and Sobal, J. (2004), “Religion, social support, fat intake and physical activity”, Public Health
Nutrition, Vol. 7 No. 6, pp. 773-781.
Kumar, R. (2021), “Impact of national health mission of India on infant and maternal mortality:
a logical framework analysis”, Journal of Health Management, Vol. 23 No. 1, pp. 155-165.
Kumar, M. and Mohanty, P.C. (2023), “Undernutrition and anaemia among Indian adolescents: role of
dietary diversity and hygiene practices”, Journal of Nutritional Science, Vol. 12, p. e33.
Meenakshisundareswari, V. (2020), Perception about SABLA scheme among the parents of
beneficiaries in Ramanathapuram district of Tamilnadu India, Department of Home Science
and Research Centre Thassim Beevi College for Women, Ramanathapuram.
Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF and Population
Council (2019), Comprehensive National Nutrition Survey (CNNS) National Report, Ministry of
Health and Family Welfare (MoHFW), Government of India, UNICEF and Population Council,
New Delhi.
Mistry, M.B. (2005), “Muslims in India: a demographic and socioeconomic profile”, Journal of Muslim
Minority Affairs, Vol. 25 No. 3, pp. 399-422.
Mutatkar, R.T. (2005), Social Group Disparities and Poverty in India, Working Paper 2005-004, Indira
Gandhi Institute of Development Research, Mumbai.
National Nutrition Monitoring Bureau (National Institute of Nutrition) (2017), “NNMB urban nutrition
report”, National Institute of Nutrition, Hyderabad.
IJSE Ohlan, R. (2020), “Muslim women in India: status of demographic, socioeconomic and health
inequalities”, Journal of Muslim Minority Affairs, Vol. 40 No. 3, pp. 429-440.
O’Donnell, O., van Doorslaer, E., Wagstaff, A. and Lindelow, M. (2008), “The concentration index”,
Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their
Implementation: A Guide to Techniques and Their Implementation, pp. 95-108.
Parveen, G. (2022), “Muslim women in India: problems and perspectives”, Aligarh Muslim University,
Aligarh.
Pathak, P.K. and Singh, A. (2011), “Trends in malnutrition among children in India: growing inequalities
across different economic groups”, Social Science and Medicine, Vol. 73 No. 4, pp. 576-585.
Ram, F. and Roy, T.K. (2004), “Comparability issues in large sample surveys-some observations”, in
Roy, T.K., Guruswamy, M. and Arokiaswamy, P. (Eds), Population, Health and Development in
India-Changing Perspectives, International Institute for Population Sciences, New Delhi,
p. 40e56.
Sachar, R. (2006), “Sachar committee report”, available at: http://www.teindia.nic.in/Files/Reports/CCR/
SacharCommitteeReport.pdf
Singh, A. (2012), “Gender based within-household inequality in childhood immunization in India:
changes over time and across regions”, PLoS ONE, Vol. 7 No. 4, p. e35045.
Tackett, S., Young, J.H., Putman, S., Wiener, C., Deruggiero, K. and Bayram, J.D. (2018), “Barriers to
healthcare among Muslim women: a narrative review of the literature”, Women’s Studies
International Forum, Vol. 69, pp. 190-194.
Tan, M.M., Chan, C.K.Y. and Reidpath, D.D. (2013), “Religiosity and spirituality and the intake of fruit,
vegetable, and fat: a systematic review”, Evidence-Based Complementary and Alternative Medicine,
Vol. 2013 No. 11, pp. 1-18.
Varadharajan, K.S., Thomas, T. and Kurpad, A. (2014), “The Indian national food security Act, 2013:
a commentary”, Food and Nutrition Bulletin, Vol. 35 No. 2, pp. 253-265.
Vellakkal, S., Gupta, A., Khan, Z., Stuckler, D., Reeves, A., Ebrahim, S., Bowling, A. and Doyle, P.
(2017), “Has India’s national rural health mission reduced inequities in maternal health services?
A pre-post repeated cross-sectional study”, Health Policy and Planning, Vol. 32 No. 1, pp. 79-90.
Wagstaff, A. and van Doorslaer, E. (2004), “Overall versus-socioeconomic health inequality: a measurement
framework and two empirical illustrations”, Health Economics, Vol. 13 No. 3, pp. 297-301.
Who (2017), Physical Activity Fact Sheet, World Health Organization, Geneva.
Yaya, S. and Ghose, B. (2020), “Change in nutritional status among women of childbearing age in
India (1998-2016)”, Obesity Science and Practice, Vol. 6 No. 5, pp. 535-543.
Zajacova, A. and Lawrence, E.M. (2018), “The relationship between education and health: reducing
disparities through a contextual approach”, Annual Review of Public Health, Vol. 39, pp. 273-289.

Further reading
Batliwala, S. (1982), “Rural energy scarcity and nutrition: a new perspective”, Economic and Political
Weekly, Vol. 17 No. 9, pp. 329-333.
Centers of disease control (2011), Body Mass Index: Considerations for Practitioners, CDC,
Washington DC.
Isralowitz, R., Reznik, A., Sarid, O., Dagan, A., Grinstein-Cohen, O. and Wishkerman, V.Y. (2018),
“Religiosity as a substance use protective factor among female college students”, Journal of
Religion and Health, Vol. 57 No. 4, pp. 1451-1457.
Navarro-Prado, S., Schmidt-Riovalle, J., Montero-Alonso, M.A., Fern
andez-Aparicio, A.
and Gonz
alez-
Jim
enez, E. (2018), “Unhealthy lifestyle and nutritional habits are risk factors for cardiovascular
diseases regardless of professed religion in university students”, International Journal of
Environmental Research and Public Health, Vol. 15 No. 12, p. 2872.
Subramanyam, M.A., Kawachi, I., Berkman, L.F. and Subramanian, S.V. (2011), “Is economic growth Socioeconomic
associated with reduction in child undernutrition in India?”, PLoS Medicine, Vol. 8 No. 3, e 1000424.
disparities in
Supplementary file nutrition

S1. Details of methods and measures used in the study

a). Poor-rich ratio: PR ratio is a simple and commonly used measure to examine socioeconomic
disparities in health, education and similar outcomes. The ratio between the (percentage) prevalence of
underweight (captured using BMI<18.5) women among the poorest category (poorest wealth quintile)
and the (percentage) prevalence of underweight women among the richest category (richest wealth
quintile) has been used to summarize economic disparity in the distribution of undernutrition. A PR ratio
of 1 indicates that the poorest and richest experience undernutrition equally, whereas a PR ratio greater
than 1 indicates that the poorest are more likely to suffer from undernutrition (Pathak and Singh, 2011).
The formula for the Poor-Rich ratio:
Percentage of underweight women among the poorest wealth quintile
PR ratio ¼
Percentage of underweight women among the richest wealth quintile
b). Disparity ratio: In terms of the ratio of percentages of highest underweight to lowest underweight
in a particular category; for example, for geographic regions (XRegions, the disparity ratio will be a
percentage of underweight in the region with the highest prevalence of underweight to the percentage of
underweight in the region with the lowest prevalence of underweight.
The formula for the Disparity ratio:
Percentage of the underweight in Xn with the highest prevalence of underweight
Disparity ratio for Xn ¼
Percentage of the underweight in Xn with the lowest prevalence of underweight

c). Concentration index: The concentration index is a commonly used measure to assess and quantify
socioeconomic inequalities in health or other indicators within a population. It provides a way to evaluate
whether certain health outcomes (prevalence of underweight in the present study) are disproportionately
concentrated among individuals of higher or lower socioeconomic status (O’Donnell et al., 2008).
In the context of health, the concentration index focuses on capturing the degree to which a health
outcome is correlated with socioeconomic status, often measured by an individual’s wealth (Wagstaff
and van Doorslaer, 2004).
The formula for the concentration index can be written as follows:
2
C ¼ :cov ðy; RÞ
μ
Where:
(1) C is the concentration index.
(2) y represents the health variable for each individual.
(3) R is the fractional rank of the individual in the wealth or socioeconomic distribution.
(4) μ is the mean of the health variable across the entire population.
The concentration index measures the extent to which the distribution of health outcomes differs from a
perfectly equal distribution (i.e., if everyone had the same health regardless of socioeconomic status).
The cov ðy; RÞ is the covariance between the health variable and the fractional rank in the socioeconomic
distribution. The μ2 is a scaling factor that ensures the index is bounded between
1 and 1 (Wagstaff and
van Doorslaer, 2004).
If the concentration index is close to 0, it suggests that health inequalities are minimal or not
strongly correlated with socioeconomic status. If the concentration index is positive, it indicates that the
IJSE health outcome is more prevalent among individuals with higher socioeconomic status, implying
inequality in favour of the higher-status group. If the concentration index is negative, it indicates that the
health outcome is more prevalent among individuals with lower socioeconomic status, implying
inequality in favour of the lower-status group.
It is important to note that the concentration index provides a numerical value for inequality but
does not explain the underlying reasons. It is often used in combination with other analyses and
complementary indicators to gain a more comprehensive understanding of socioeconomic inequalities in
health.
d). Logit model: A logit model, also known as a logistic regression model, is a statistical technique used
for modelling the relationship between a binary outcome variable and one or more predictor variables
(Cox, 1958). It is particularly useful when there is a need to predict the probability of an event occurring,
given certain input variables. The relationship between the predictor variables and the binary outcome
is modelled using the logistic function. The logistic function transforms a linear combination of the
predictor variables into a value between 0 and 1, which can be interpreted as a probability. The
coefficients of the predictor variables in the logistic function are estimated using methods like maximum
likelihood estimation. These coefficients represent the strength and direction of the relationships
between the predictors and the log odds of the binary outcome. Using the estimated coefficients and the
logistic function, the predicted probability of the binary outcome for specific values of the predictor
variables is calculated. This probability reflects the likelihood of the event occurring given the predictor
values, which is the outcome of being underweight among women of reproductive age in this study.
The formula for logistic regression relates the probability of a binary outcome to a linear
combination of predictor variables using the logistic function (also known as the sigmoid function). The
logistic regression equation can be expressed as follows:
1
PðY ¼ 1Þ ¼
−ðβ0 þβ1 X1 þβ2 X2 þβ3 X3 þ:::þβp Xp Þ
1þe
Where:
(1) PðY ¼ 1Þ is the probability of the binary outcome of women being underweight.
(2) β0 ; β1 ; :::; βp are the coefficients of the logistic regression model.
(3) X1 ; X2 ; . . . ; Xp are the values of the predictor variables.
The logistic function, represented by 1þe1 −z , transforms the linear combination of the predictor variables
and their coefficients z ¼ ðβ0 þ β1 X1 þ β2 X2 þ β3 X3 þ:::þβp Xp Þ into a value between 0 and 1, which can
be interpreted as a probability (Cox, 1958).
e). Predicted probability: Predicted probability refers to the probability of a binary outcome,
meaning an event that can have only two possible outcomes, such as yes/no, success/failure, or 1/0. For
example, it could be used to predict the probability of the prevalence of underweight among women (yes/
no) based on predictor variables like caste, place of residence, education, wealth quintiles, region etc. It
gives an estimate of the likelihood of the event happening; if the predicted probability of being
underweight is 0.75, it suggests a 75% chance that a woman is underweight, given the predictor
variables (Muller and Maclehose, 2014).
S2. Percentage prevalence of undernutrition (captured by underweight) among women in Socioeconomic
India by socio-economic characteristics, 1998–2021
disparities in
nutrition

Socio-economic characteristics NFHS-2 NFHS-3 NFHS-4 NFHS-5

Religion
Hindu 37.42 33.93 19.16 14.26
Muslim 34.16 32.14 15.99 10.77
Christian 25.06 19.43 10.91 8.61
Sikh 16.62 11.85 7.05 6.55
Buddhist 33.91 38.23 19.13 13.95
Jain 15.95 12.89 6.38 7.32
Others 48.12 42.26 23.38 20.21
All-India 36.29 33.01 18.37 13.58
Caste
SC/ST 44.10 41.70 23.45 17.01
OBC 36.14 32.66 17.88 13.30
Others 31.08 26.35 13.56 9.94
Place of residence
Urban 22.74 19.81 10.01 7.56
Rural 41.23 38.83 22.58 16.32
Education
No education 43.44 41.01 23.90 16.85
Primary 35.96 32.37 19.57 13.86
Secondary 26.88 24.78 15.53 12.84
Higher 15.63 11.45 8.60 7.98
Wealth quintiles
Poorest 50.66 51.19 33.08 24.23
Poorer 46.85 45.24 25.4 17.49
Middle 41.16 35.19 17.82 12.68
Richer 30.23 24.02 11.52 8.85
Richest 14.51 11.74 6.05 5.12
Region
North 27.77 25.72 14.26 9.65
Central 37.47 36.51 21.01 14.32
East 43.15 40.49 23.3 16.81
West 39.28 32.43 19.76 16.42
South 33.13 26.75 12.39 9.98
North East 26.48 32.00 19.83 12.87
Note(s): SC/ST5Scheduled castes and scheduled tribes; OBC5Other backward castes
Source(s): Author’s calculation based on NFHS-2, NFHS-3, NFHS-4 and NFHS-5 data
IJSE S3. Percentage prevalence of undernutrition (captured by underweight) among women in
India based on NFHS, 1998–2021
S4. Percentage prevalence of undernutrition (captured by underweight) among Muslim Socioeconomic
women in India based on NFHS, 1998–2021
disparities in
nutrition
IJSE S5. Trends in socio-economic disparities based on disparity ratios with respect to
undernutrition (BMI<18.5) among Muslim women, India, 1998–2021

NFHS-2 NFHS-3 NFHS-4 NFHS-5

Caste 1.06 1.27 1.32 1.33

Place of residence 1.55 1.88 1.97 1.77
Education 2.12 4.57 2.34 1.96
Region 2.07 2.63 3.30 2.23
Wealth 3.04 4.46 4.55 3.75
Source(s): Author’s calculation based on NFHS-2, NFHS-3, NFHS-4 and NFHS-5 data

References (Appendix)
Cox, D.R. (1958), “The regression analysis of binary sequences”, Journal of the Royal Statistical Society:
Series B (Methodological), Vol. 20 No. 2, pp. 215-232, doi: 10.1111/j.2517-6161.1958.tb00292.x.
Muller, C.J. and Maclehose, R.F. (2014), “Estimating predicted probabilities from logistic regression:
different methods correspond to different target populations”, International Journal of
Epidemiology, Vol. 43 No. 3, pp. 962-970, doi: 10.1093/ije/dyu029.
O’Donnell, O., van Doorslaer, E., Wagstaff, A. and Lindelow, M. (2008), “The concentration index”,
Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their
Implementation: A Guide to Techniques and Their Implementation, The World Bank,
Washington DC, pp. 95-108.
Pathak, P.K. and Singh, A. (2011), “Trends in malnutrition among children in India: growing
inequalities across different economic groups”, Social Science and Medicine, Vol. 73 No. 4,
pp. 576-585, doi: 10.1016/j.socscimed.2011.06.024.
Wagstaff, A. and van Doorslaer, E. (2004), “Overall versus-socioeconomic health inequality:
a measurement framework and two empirical illustrations”, Health Economics, Vol. 13 No. 3,
pp. 297-301, doi: 10.1002/hec.822.

Corresponding author
Ashish Singh can be contacted at: singhmb.ashish@gmail.com

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