[0:15]Hello everyone. I would like to welcome you to my first session. We will start first session with NFHS 5 data which is just come out recently. This is to understand the problem of undernutrition in India. Okay, so let's understand what uh what data shows us. This is NFHS 5 data, National Family Health Survey. Okay. And basically here in the first slide what you're seeing is the age wise distribution of nutrition indicators. Okay. So age wise in a sense that what we have done, whatever data that NFHS 5 had, we have distributed among the uh different age groups. Okay. So here in um you have uh months, 0 to 2 months, 3 months, 4 to 5 months of baby, 6 months, okay. And here you have a percentage on a Y-axis. So here we have taken three indicators. Uh for example, uh blue is your wasting. Uh your yellow line, yellow bar is your underweight. And red one is your stunting. Okay. So we want to kind of show that what NFHS 5 showed is basically between 0 to 2 months of age, you have almost 30% children who are wasted. Okay, almost 30%. Uh 30% children are underweight. And uh about say 28% are stunted. That means right at births, and in first two months, almost your 1/3 children are not doing well, okay, 1/3 children that's a huge lot of number. Now, when you, you know that, in first two months, what matters, mother's nutrition during pregnancy and your breastfeeding, okay.
[2:11]That means our mothers are not getting enough uh nutritious uh rich food, so babies are of course grown uh low birth weight. And also even if they are probably growing uh well, but because probably the latching or the milk transfer is not good from mothers to babies, okay. And that's why you, you know, you need to have a good amount of catchup growth and maximum occurs in first two, three months of age, you know, and that's not occurring. Okay. So not only there is a tremendous amount of growth faltering occurring in first couple of months, but uh also growth catchup is not occurring. Okay. So this is very, very uh important to understand that first two, first 0 to 2 months of age, uh a lot of these babies are, you know, not not doing well. Looking at 3 month data, uh again if you look at your wasting, wasting from say around 29% has gone down to maybe 26%. Not not much decrease in wasting. Okay. And your underweight pretty much stays same. Okay. Uh there is a little bit of stunting uh decreasing, which is good. Uh but then let's go back to again four to five months of age, and then look at the again the wasting has not decreased much. Uh underweight has not decreased much and stunted stunting stays as it is. Okay. And that's the same trend that you see in uh six months of age babies also. So what we are seeing is that in first six months of age, where there should be tremendous amount of growth catchup occurring, there should be uh almost zero growth faltering occurring should be occurring but probably we are getting a lot of growth faltering and very poor growth catchup. Okay. Now this again up to six months is all breastfeeding. Okay. Nothing else. So uh of course milk transfer is a problem. Uh probably many mothers are giving uh cow's milk and babies are getting diarrheas, okay, so we have to also consider that. Uh starting from 7 to 12 months of age. Now this age group, this is where there is introduction of complementary feeding and mother is learning how to introduce complementary feeding and how to increase dietary diversity and how to increase the frequency and the quantity. Okay. So if you look at it, there is little bit of improvement in wasting, but look at the underweight and stunting going up. Okay. This means that babies who are already malnourished in first six months, they are becoming much more malnourished because there is no proper support of complementary feeding in this age group. Okay. So now you can see how uh all your underweight as well as your stunting going up. Okay. Uh very, very crucial stage. We have seen many babies who grow beautifully on mother's milk till six months of age, but if mother is not supported on how to uh give complementary food, uh they become thin. You know, they lose lot of weight and they become thin. Okay. Uh and then let's go to one to two years of age. Now in one to two years of age what you see is basically now look at the stunting. Literally from uh from 0 to 2 months you had about 28%, now it's almost reaching to 40%. Okay. That significantly high number of stunting at uh between one to two years of age. This means that completely the failure of first year of uh life uh when it comes to IYCF. Okay. IYCF is your uh maternal infant young child nutrition. So not only maternal nutrition has gone wrong, but uh also your breastfeeding has gone wrong and also your complementary feeding rate has gone up. So it's basically ongoing chronic condition and that's when you see remarkable increase in stunting. As the baby is getting stunted, obviously baby's bones are small, so now you have underweight also, you know, short babies always kind of weigh underweight, unless uh child puts on lot of fat. Okay. So this is important that uh, you know, uh there is significant reduction or uh I would say, significant uh increase in uh stunting and uh underweight. Okay. As stunting increases, you can see wasting decreases. Okay. Now this uh, in my uh, my opinion is that as babies become shorter and shorter, you know, uh your wasting is getting masked. Okay. Because that shorter baby does not need to have that much weight, okay, uh to to not come underweight, graph. Okay. So that's why this is this is paradox as the stunting goes up, your wasting comes down, but this is masking of wasting. Okay. Then comes your uh two to three years of age. In two to three years of age what you can again see not much decrease in stunting. Uh look at the underweight going up. You know, it has gone up now from 30, 31% to almost uh 34%. Okay. Uh and again not much decrease in wasting. Uh similarly in this graph you can see that uh, you know, from three to uh six years of age. Uh actually five years of age, three to five years of age, uh you can see pretty much the same uh graph, again stunting and underweight pretty high and then your uh wasting is kind of uh, you know, uh lingering around uh 16 to 17%. Okay. So this age wise uh change uh in your uh underweight, wasting and stunting is very important to understand because once you understand the uh data, you will understand the root cause and then you'll be able to give the good solution, okay. So I'm going to come to another bar graph, this is undernutrition in India according to residence, residence in a sense that urban or rural area, okay. So here uh if you look at stunting data, obviously stunting in uh uh you know, your rural area is much higher than your uh urban area. Okay. Pretty much same thing for underweight also. Uh wasting not much difference, so in wasting your urban or rural has equal uh number of wasted children. Uh underweight and stunting, yes. Because of course as child is stunted, child is going to be underweight because bones are small. Okay. Uh this is uh as per gender. So as per gender you can see that uh males are a little bit higher when it comes to stunting and underweight. Wasting is not much difference, but little bit of just just minor difference, but again, you know, uh males are at disadvantage, you know, uh normally what you would see that, you know, uh in India especially you will see girl children being more uh, you know, uh underweight and of course wasted and stunted. But uh it's nature is protecting this girl child because eventually she's going to uh bear a baby, you know, so she uh she is protected, not that I'm saying too much of protection, but uh it's probably nature's way of protecting a girl child. Okay. Uh we need to work on all these indicators, understand uh the root cause, understand the issue, uh and then we can definitely kind of understand the the, you know, uh solution and then we'll come come with excellent results. Now, this is another very good uh pie chart. Again undernutrition prevalence among children below five years of age. Okay. So, uh see, out of 100%, about 47.8% are absolutely normal when it comes to wasting, stunting and underweight. Okay. So that's pretty low number actually. You want almost 96% children to be in this uh category, uh all normal, but you have only 47.8%, which is almost half. Okay. Uh here what we have, what we have done is basically we have seen, we have taken data of babies, children under five years of age, who are only stunted. Okay. Only stunted, no no underweight and no uh wasting also. You, so you have about 15% children who are only stunted. Uh only wasted children are, children who are only thin, wasting means thin, you know, child is thin, right. So only uh wasted children are about 6.5%. Okay. Uh only underweight children are 2.3% so that's a very low number, okay. Uh generally underweight is usually associated with either wasting or stunting. Okay. Very rare to have uh, you know, underweight. And these are the children probably, you know, uh might have just uh, had one or the two uh acute uh infection and suddenly weight has gone down but not gone down as much that it shows up on wasting graph. Okay. Uh about uh there is uh 0% babies who are uh only stunted and wasted, okay, so 0% uh in uh that. And uh when it comes to uh stunting and underweight, uh the reason you have only 0% stunting and wasting because stunting and wasting is always associated with underweight. Okay, so you want to remember that that whenever you have a stunted child and wasted child, child has to be underweight, okay. And that's why it's showing 0% uh not if you don't include underweight, okay. Uh when you have a stunted child and underweight child, about 15% children are stunted and underweight, okay. Now these children are probably uh the uh Sam is masked because child is short and as child is short uh, you know, child is also underweight. Okay. That's a significant number, 15.5% children are stunted and underweight. Okay. Now you have underweight and wasted. So you have about 7.5% children who are underweight as well as wasted. Okay. So these are the children probably uh child is doing metabolically really well, means child has stunting, you know, child has, child doesn't have stunting, uh but probably had some infection, you know, lost some weight, acute weight, you know, has become wasted and because child has lost weight so it become underweight also. So about 7.5% children are wasted and underweight. Okay. And if you look at all the three indicators, which includes your stunting, wasting, underweight, you have about 5.2% children who have all three indicators and these are the children who are at very high risk of uh lot of complications. Okay. Because you have this chronically malnourished child who is stunted, now is becoming wasted, okay. So, uh, of course mortality also increases in this this children. Okay, who are stunted and your wasted. Okay. So this is another very important graph uh, which is uh important to understand. Okay. Now, let's talk about the prevalence of stunting. Okay, stunting means your child children are short. Okay. So this is again uh you have the graph of India in front of you. Uh this is Bihar, so you can see that in Bihar you have very high uh stunting rate. Uh almost you can look over here. Uh this is your India stunting level, which is about 36%. 36% children are stunted in India. And uh if you look at last few states, you can see Meghalaya, Bihar, Uttar Pradesh, Jharkhand, you know, Dadra Nagar Haveli, uh these are some of the states which are uh, kind of doing, even Gujarat, in fact, if you look at Gujarat, uh Gujarat is doing worse when it comes to uh stunting level. Okay. And here again this are all the states that we have shown. Here is your Meghalaya, this is your Bihar, you know, uh and these are uh data which is showing more than 40%. Okay. And then between 30 to 39% it's all your red zone. So basically pretty much the whole of India has more than 30% uh, you know, uh stunting rate, which is significantly high. As I mentioned to you, we want only maybe two to 2.5% children who are uh, who should be or who may be less than -2 standard deviation. But instead of having 2.4 to 2.5% children being stunted, uh we have uh significantly you can see the whole of India is pretty much 30% and above, okay. Uh let's talk about underweight. Underweight is also uh average underweight in India is about 32%. But if you look at all these states, uh you know, again, uh pretty much the same uh states that, you know, I mentioned for stunting, which is your Bihar, Gujarat, Jharkhand, Dadra Nagar Haveli, Daman and Diu, you know, Maharashtra, many, many states are not doing uh good compared to India. Of course India by itself is not doing well. When you have uh 32% underweight, that's pretty significantly high actually. Okay.
[16:04]Uh states which are doing reasonably well, I would say reasonably well compared to India standard, not necessarily for world standard. Uh you have uh a couple of states, you know, few states from northeast, your Mizoram, Sikkim, Manipur. Puducherry is doing pretty, pretty good compared to India. Okay. And also Arunachal Pradesh and Punjab. Here you can see again pretty much the same, you know, uh states, uh you can see red, uh all the red areas are all underweight about 30%. Okay. Uh not that we want 20 to 29% children underweight, but you know, just comparison to to India standard. Okay. Now this is wasting, wasting means acute malnutrition. So your Sam, Mam comes under wasting, okay. You're thin, like as per height, what is the weight of that child. Okay. So again if you look at it, uh average uh wasting in India, it's about 19%, you know. Uh so there are many states which are uh worse than uh India standard, okay. And that you uh you again see pretty much, you know, your Maharashtra, Gujarat, Bihar, Jharkhand, Assam, Telangana, you know, Dadra Nagar Haveli, Daman and Diu. So these are all basically not doing well. Here is your uh, you know, again your red uh areas. Uh wasting is pretty significant.
[17:36]Now suppose if child is doing very well, if child is growing well in terms of height, and if suppose child uh for couple of days or few days hasn't eaten because of some diarrhea, pneumonia, uh you definitely want to treat those infection, but they come out pretty fast. Okay. If their metabolism is very good, uh, you know, they come out of infection very fast. But what I saw in my program, the children who were stunted already, they were not growing well, uh, you know, they were chronically malnourished. When they got diarrhea, it got very difficult to bring that child uh out of uh wasting, okay. So you want to make sure that you're just, you know, that uh longitudinal data is more important than the cross sectional data in wasting. Okay. So cross sectional means uh, you know, you just measure uh weight for height, even say once once and tell, uh, you know, tell that, oh, this child is wasted.
[18:34]Uh generally I prefer that we have a longitudinal uh checkup, so if child is growing well, uh, you know, uh height child height wise child is growing well over a period of time, uh sometime when they have again infection, they would get uh thin, they would lose weight. Uh, but again those children come out very fast when you treat the infections. Okay. So that's important. Uh, you can see some of the economically advanced states are quite red in color. So Maharashtra, Gujarat, you know, some of those states are not, I mean, you know, we did not expect this children to be wasted. But again, uh, just looking at wasting data, I, you know, I won't comment, you know, we have to also look at uh stunting stunting in the states. And stunting is also kind of high in both the states. So both the states are not doing well as when it comes to child child child nutrition. Okay. Uh now let's look at anemia. Uh this is your urban area, rural area, total anemia. Uh any anemia, so you have different kinds of anemia. So any anemia almost 65% children are anemic, okay. Uh total, uh of course higher in rural areas. Uh when you look at mild, moderate and severe anemia, uh again, uh, you know, uh you have uh basically almost 30% children who come into mild category. Moderate category you have about uh, you know, uh about 35% children in rural areas and about 32% children in urban areas. And severe anemia almost two to 3% children are severely anemic, okay. And total, uh any anemia means mild, moderate, severe. So if you calculate all three of them together, uh you know, just randomly take any child who is uh, you know, anemic, uh that number is significantly high. Okay. Uh and unfortunately what happens when you a diagnosed with anemia and say uh nine months to one year of age, uh those babies already kind of have poor IQ because once you diagnose that means anemia has already kind of caused impact on their brain. Okay. Because uh you need good amount of oxygen uh going to child's brain because brain is growing very fast. So this one is really crucial that we prevent anemia, okay. Not of course, we have to treat this anemia children also, but uh again, mother's milk and complementary food which is high in iron, uh the counseling is very, very important for mothers, okay. Uh here you are looking at uh anemia among children in India, uh according to gender. So if you look at gender, again, you know, uh in young children up to five years of age, uh there is not much difference, okay. Uh this of course girl children are not menstruating, so they are not losing uh blood. So this is all basically diet related anemias. Okay. And uh here you can see both both boy and a girl child uh almost 65% children are anemic, okay. Not much difference gender wise. Uh when you look at, you know, the graph of India, uh this is again you can see almost uh 60% children are anemic, okay. So we want to make sure that, you know, we give uh again nutrition counseling is very, very important. Uh six almost look at the 65% children are anemic.
[22:14]Ladakh is almost reaching uh 90 to 92%. So Ladakh, you know, we need to kind of really intervene in Ladakh. Uh Gujarat also, a lot of the states, again, same Dadra Nagar Haveli, Daman and Diu, you know, these are all uh states, you know, that we can uh basically work on, uh to improve anemia, okay.
[22:42]Uh this is status of key breastfeeding practices, NFHS 5. So if you look at uh, uh, what are your breastfeeding indicators, okay? Breastfeeding indicators is uh early initiation of breastfeeding and your exclusive breastfeeding rate. Okay. So you look at uh early initiation of breastfeeding. Now we know that uh institution delivery has gone really high up, you know, uh more than 90% deliveries occur in institution institution, but look at the number of children who are given breast milk uh in the hospital within one hour. Okay. Very poor, 40% only, okay? Urban maybe around 42, 43%, but rural areas is 40. The total comes out to be 41, 42%, not more than that. Okay? So here we can really improve this uh any early initiation of breastfeeding. You will see in one of my session that how that, why early initiation is so important and what happens when you don't uh give breast milk within one hour. That colostrum is extremely important to develop good immunity, gut microbiome, okay, uh to prime that baby. It's like, you know, when we take vaccine, so when you, when you vaccinated with the baby, you, you basically priming that baby for uh infections in the in the future, right? Similarly, when you give breast milk first thing immediately, as soon as baby's born, that colostrum has, uh, you know, uh good bacteria of the mother. Colostrum has human milk oligosaccharide and that's going to stimulate baby's immunity and it's going to fight infections, not only immediately, but lifelong. Okay? So very, very crucial that you work on this early initiation of breastfeeding. Uh another thing is ever breastfed child who received prelacteal feed means babies who get say uh something other than uh breast milk, okay? So a very significant number of children they get uh prelacteal feeds, uh, you know, you can see it uh almost uh 20% children are getting prelacteal feeds, which is something other than breast milk. Okay. Uh what is the status of key breastfeeding practices? Again, if you look at uh the region wise. So all these areas, uh, you can see all this red zone, uh, only uh early initiation of breastfeeding is uh only between uh 12 to uh 40%, okay? Uh, which is which is significantly uh poor. Uh you can see in India, uh only 42, 42% of children are getting early initiation of breastfeeding. Uh many areas, uh, there are have early initiation of breastfeeding, uh your Meghalaya has good amount of early initiation of breastfeeding, Lakshadweep, Odisha, you know, Kerala, right? Uh, some of these areas like Jharkhand, Uttar Pradesh, Daman and Diu, Dadra and Nagar Haveli, Bihar, uh these are the areas that we saw they are not doing well when it comes to uh nutrition indicators and they are not even getting breast milk in first five uh first half an hour or so, you know, half an hour to one hour, okay? So you want to improve those states, you definitely want to improve your early initiation of breastfeeding. If you look at exclusive breastfeeding, uh look at the exclusive breastfeeding rate in India is about 62, 60, 63 to 64%. Okay. Uh many mothers around 75% of the mothers, they start exclusive breastfeeding. They want to, they, they start with exclusive breastfeeding, but there is a, there is a breastfeeding failure. So you can see the failure that as child is growing up, you know, the exclusive breastfeeding rate going down. This mothers means they are not getting support from healthcare workers on how to breastfeed. So there is poor milk transfer, weight gain is not happening. And then probably pediatricians are starting formulas. Many pediatricians, they do start formulas right away. We have to also understand that, uh, this is absolutely not needed. Uh, so, uh, this is also for pediatrician to please uh, kind of start uh, breastfeeding, exclusive breastfeeding at birth, as well as up till six months of age. Okay. And again not much difference when it comes to urban rural, rural exclusive breastfeeding rate is little bit higher than urban area. Uh again, if you look at exclusive breastfeeding rate, uh in India, you know, uh many states which are giving exclusive breastfeeding rate, uh, I mean, uh exclusive breastfeeding to babies but they are not doing well when it comes to nutrition indicators, okay? So if you look at exclusive breastfeeding rate, it's not enough. You have to look at early, effective, and exclusive. So I, I strongly believe in triple E early, effective and exclusive breastfeeding rate. Okay.
[29:23]Uh, this is about complementary feeding at 6 to 8 month again, uh many, uh sorry, again, uh lot of the states, uh in red zone, uh are not getting complementary, uh complementary feeding by 6 to 8 months of age. So this states need to improve remarkably. Uh again, your UP, Rajasthan, Jharkhand, Bihar, you know, this this states, uh, you know, states in the middle are not doing very well. Okay. Uh this is minimum acceptable diet. So minimum acceptable diet is your uh dietary diversity. Your frequency and your both together is your minimum medical diet. So again in India, breastfed babies and even non-breastfed babies, only 10 to 11% babies are getting minimum adequate diet. That means enough frequency and enough dietary diversity. Okay.
[30:22]Uh, can you imagine only 10% to 12% babies are getting proper complementary food, uh under, you know, two years of age. If this children don't get proper complementary food, believe me they're going to become wasted. They're going to become underweight, stunted, okay. So this is important. Uh, again this is age wise category of your minimum adequate diet. Uh MAD, I'll focus on MAD which is your minimum adequate diet, which includes your frequency as well as your dietary diversity, okay. So very, very poor uh uptake of complementary feeding, uh up to two years of age as you can see, uh age wise, it's pretty poor. Okay. Uh thank you so much. As now we understood NFHS 5 data very well, uh let's see what uh I'm in next session, I'm going to talk about uh what exactly we did uh in urban slums and other areas of uh India to improve this uh indicators. And it's a small, of course, small program, but in those small programs we learned uh lot of uh, you know, loopholes and how to kind of come up with solutions to to manage this malnutrition in among those underprivileged children. Okay. Thank you.
