Determinants of Nutrition Agenda Setting in the Context of the Double Burden of Malnutrition in Tamil Nadu, India

The double burden of malnutrition is increasing in low- and middleincome countries, with economic, social, and health consequences. Policies and programs to address malnutrition at the national and subnational levels reflect the priorities and framing of the problem by the stakeholder community. Previous studies have examined if and how nutrition-related NCDs have been included into national nutrition policy agendas that have historically focused on reduction of undernutrition, but little is known about if or how this process occurs at the subnational level where policies are translated and implemented according to local contexts, priorities, and frames of nutrition-related NCDs. We aimed to improve understanding of the determinants of nutrition agenda-setting in the context of the double burden of malnutrition in Tamil Nadu, India through in-depth interviews with state- and national-level nutrition stakeholders (n=28). We used a grounded theory method of analysis to construct stakeholder frames of undernutrition and nutrition-related NCDs and show how different frames held by stakeholders reflect intention and action regarding nutrition policy and programming. We mapped emergent themes to a determinants of political priority framework to identify the conditions and characteristics that support and inhibit the inclusion of nutrition-related NCDs in the nutrition policy agenda. Contrary to the framing of undernutrition, framing of nutrition-related NCDs lacked consistency with respect to health conditions, risk factors, target populations, roles for stakeholders, and program and policy effect on malnutrition. Comparison of the two frames suggests three challenges to bringing nutrition-related NCDs to the state nutrition policy agenda: prioritization of the problem, coherence by the policy community, and convergence of efforts to address them. Implementation of the recently released National Nutrition Strategy presents an opportunity to integrate nutritionrelated NCDs into the state nutrition agenda, but leadership and responsibility among policy actors for addressing them is weak. The ways that nutritionrelated NCDs are understood by stakeholders and portrayed to others highlight the lack of coherence within the policy community and the negative social constructions of those who suffer from them. Efforts to address the double burden of malnutrition at the subnational level must first overcome these barriers