 Hello everyone, so this is going to be session number 3 and in this session I am going to talk about hidden hunger and types of malnutrition, very important we have already discussed about type 1 and type 2 nutrient, I will touch base upon it because primarily our types of malnutrition depends upon what kind of nutrients are lacking in children, so I will again touch base on that, but let us start with the types of malnutrition, so basically we all know there is hunger, but there is a difference between actual hunger and hidden hunger, hunger means like you do not have food to eat, so when you say that child is hungry, basically there is no food to eat to the child, in India we do not see hidden hunger as much because through PDS system, children are getting some food of course, they are getting rice, depending upon its state they are, they get THR, take home ration, they get meat and meals, so they do get food, it is not that they go really hungry, very few, I would say literally very few percent of children have really no food, but generally in my experience in working in slums of Mumbai, I hardly saw any child going hungry, so in that hunger when a child is hungry, obviously child is not getting enough calories, but main thing is child is not getting lot of nutrients also, so absence of calories is just child is not getting food, that is what is called hunger and it occurs mainly in situation like famine in food insecurity and generally in a world there are about 1 billion hungry children, so we do have issue of poverty occurs in war stricken areas and food insecure areas or during famine time or in emergencies, what is hidden hunger, so if you look at, if you ask any mother in slums or even rural areas or tribal areas or even regular day to day middle class family, mostly their diet is roti, sabji some, some sabji, dal and rice, very monotonous food, so they have rice in the morning, so they have either poha or they will have wheat, so upma or idli or any of those, so grain, grain based diet in the morning, afternoon it is mainly roti sabji or roti, and evening they have like depending on stage, occasionally kichiri or some, maybe some vegetable, so very monotonous diet that we Indians eat, by and large I am talking about on a day to day basis, they might be sometime that you may have more dishes, but by and large routinely we eat very monotonous diet and that has changed in past few years and when you eat such monotonous diet then you will not get many of these nutrients which are required for child to grow, so that is called hidden hunger, which child's stomach is getting filled with this food because he is eating on this food, but what is required to grow that child, that is not going in his stomach or that is not going in his body and that is called hidden hunger, so we will focus on hidden hunger and why it occurs, so obviously now as you have already gone through type 1 and type 2 nutrient you know from a tutorial and also my session, so here let us apply it in the field like you know apply it and let us figure out like what is hidden hunger and then discuss in a bit more detail about some type 2 nutrient, one type 2 nutrient we have already discussed is protein you know, but here I am going to discuss many more like other micronutrients which are probably lacking in a diet, so here if you look at type 1 micronutrient deficiency here the child, normal child who does not have type 2 nutrient deficiency in the diet and if suppose this child say develop type 1 deficiency, so for example say iron, so look at the growth of this child, the growth is absolutely normal, but here in this child because even here the growth is normal, type 1 initially growth is normal, so the growth does not get affected same height, even the arm circumference looks the same, so you know muscle mass is still the same, but what happens you see the symptoms of type 1 deficiency, so here because child is iron deficient, you seeing child is probably pale, now look at the type 2 deficiency, now type 2 deficiency when child has enough type 2 nutrient rich food, they height and weight looks good, but when you have child who is deficient in type 2 nutrient say for a long period of time you see stunting, so here see you can see the growth has stunting, when the type 2 nutrient is deficient for say shorter period of time, you know say child has diarrhea, child did not eat anything or say over period of you know 2, 3 or maybe 4, 6 weeks child did not get protein in the diet or some important nutrient you know type like which is required for growth, you will see that you know child initially will have wasting which that means the muscle mass has you know kind of felt it and then eventually the height will suffer, so that is your that is a difference between a type 1 and type 2 deficiency and what you will see mainly the growth, so most important is the growth, so growth failure is your type 2 nutrient deficiency, specific signs and symptoms of some metabolic disease, metabolic condition like for example say or I would say myocomical reaction, so that is your type 1, so in iron deficiency you will see anemia, in calcium and vitamin D deficiency you will see the pits, so very specific, very specific you will know where exactly which organs are involved, if it is vitamin A deficiency you will notice that child has you know night blindness or child has you know cirrhosis, dryness of conjunctiva you know or child has immune problem you know they have more, they do not have good resistance to infection, so those are basically you know those are very specific kind of signs and symptoms that you see with type 1. Growth is not affected initially, growth may affect it may be late in the stage, so if the growth is affected is basically a type 2 nutrient, so here I have mentioned already about what are type 1 functional nutrients and type 2 growth nutrients, mainly type 1 nutrients I again mention iron, iodine, copper, calcium, selenium, all your vitamins, your fat soluble vitamins, your B complex you know your water soluble vitamins, then your type 2 nutrients are basically you know your essential amino acids, your essential fatty acids, your minerals you know potassium, magnesium, phosphorus, sulfur, zinc, sodium, chloride those are your type 2 nutrients okay and this already I have discussed, so I may not go too much in detail, remember that type 2 is growth failure, type 1 is initially there is no growth failure okay, in type 2 when it gets very severe child's appetite gets affected okay, so those children are basically they are called complicated, severely equipped malnutrition because when malnutrition becomes very severe, when the wasting becomes very severe they don't lose appetite okay, in type 1 by and large there is not we don't see much loss of appetite in this children okay, again this is same thing again you know I don't want to go too much in detail because we have already discussed about it, signage symptoms of type 2 deficiency, what are the three things that we check for growth, we check weight, we check length or height or we check muarck, mid-aparam circumference, so any of these are affected that means it's type 2 nutrient, so please in your program do focus on type 2 nutrient food, food, mainly complementary food and your pregnant mother's diet, lactating mother's diet, tell mother to start giving type 2 nutrient dense food in children's diet, they will grow beautifully and in my protein I've already mentioned which are protein rich food is basically your eggs, you know if child is non-veg start with meat, start with fish, you know start with bone broth, you can start those as first foods, lot of countries in Europe are recommending those non-veg diet to begin with, egg is the best food to start actually, but if children are vegetarian then you can start basically more than dolls I would recommend, beans, just sprouted, you know dry it, make powders, I'm going to show recipe of those powder recipes, you know those beans also, you can also start with dahi, also start you can give paneer, don't give milk because mother's milk is good enough, so you don't give milk otherwise the mothers will stop giving their own milk, right, but then also think of adding some seed powder, some nut powder, peanut powder and those are protein rich recipes, but also think of you know other nutrient which today I'm going to discuss is magnesium, potassium, zinc, sulphur, those are all type 2 nutrients and those are basically hidden hunger, so if child is getting food but if child does not have you know food which is rich in magnesium or potassium or zinc, you know those children will have you know type 2 deficiency, okay, they will not grow well, okay, so and some of them are kind of rate limiting nutrient means even if you give a lot of protein but if that protein source doesn't have say enough zinc or enough magnesium or any of those, you know children will not grow, okay, so that's called your hidden hunger, okay, now these are type types of malnutrition, so basically when you say child is malnourished or even if you say adult is malnourished, malnourished means obesity means big, over or under, okay, in India now we are saying both, we are saying under nutrition also, we are seeing all these adults are big, huge, if you look at the tummy, if you do your waist circumference is much bigger, okay, in some states it's like 80 to 90 percent women have waist to the pressure much higher, okay, higher than normal, all right, so that means we are struggling with both, our children are not growing, okay, they are under nourished, they are stunted, they are underweight and our older people are becoming big, so that means something is wrong in food, right, I mean if you give, if you getting say right kind of nutrition why would you become big or why would child become under nourished, right, so think about it, second thing is our children are becoming big too, so in urban areas and some of the rural areas, you know, some of the children are very thin, some of the children are very fat, big, okay, so think about it and why that is happening, okay, now obesity again I will discuss it later in, you know, other sessions, but I will not discuss obesity right now, today I am going to talk exclusively about under nutrition, okay, so type 2 nutrient as I mentioned that they are underweight, they are stunting and they are acute waisted, acute waisting means suddenly become thin, okay, so the height is not suffered but suddenly they have become thin because of diarrhea or some type 2 nutrient deficiency over a short period of time, chronic stunting, stunting means height, so if you look at height for age or length for age that is also type of malnutrition, type of under nutrition, okay, short children, that means they are stunting, they are under nourished for a long period of time, it is called chronic, chronic means for a long period of time, okay, acute means suddenly, okay, that is a term, medical term, acute and third is underweight, so if you weigh the child and say the average weight of a child for that age is say 10 kg, the child is only 7 kg, your child is only say 6 kg, that means the child is underweight for that age, right, and that basically that is also type of under nutrition and that is your type 2 nutrient because this is all growth, right, your weight, your height, your, you know, waisting, your mid upper arms circumference, those are all growth, okay, so when you have type 2 nutrients you will see growth failure and to look at growth failure whether it is in the short duration time or a long duration time, you look at whether it is acute malnutrition or whether it is the chronic malnutrition, okay, and then you have type 1 nutrient deficiency, so remember type 1 what your nutrients I mentioned, I mentioned about iron, I mentioned about calcium, I mentioned about iodine, vitamin A, vitamin C, vitamin B, those are all basically type of nutrient deficiency and in that as I said you will not see much of nutrient deficiency with the growth failure but what you will see is you will see symptoms, okay, now let us come back to your type 2 nutrient deficiency, so in type 2 nutrient deficiency, suppose you have underweight child, then I am going to come back again and explain to you those growth charts but just for this particular session, remember that any of this growth failure either they are severe means very severe means really bad or moderate means moderate, okay, so each growth failure are divided into moderate for example underweight, moderate underweight, severe underweight, stunting, moderate stunting, severe stunting, okay, and wasting, moderate malnutrition, acute malnutrition, severe acute malnutrition, so when we talk about SAM-MAM that is your, you know, undernutrition or wasting in a short duration, okay, and that is your acute malnutrition, okay, now how they are defined, basically what they do, they look at your growth chart, they use the Z score W to your growth chart, so standard deviation, okay, so that I will explain in my last session, I will explain those growth charts, so then I will come back again and do that, what are which children are SAM, which children are MAM, how will you know whether they are SAM-MAM, okay, so we will go in detail in that, I do not want to go too much in detail in this lecture, and SAM is divided into basically, you know, non-idimiters, but sometime, you know, the severely malnutrition have a lot of swelling in the body, so when you basically, when you, when you press their, you know, feet, when you press their, you know, legs or hands, they have a lot of edema, okay, they have beating edema, so those children are basically, we call it edema, edema is acute malnutrition, when you have some children, they do not have edema, they look very thin, okay, there is no edema, so those are non-idimiters, acute malnutrition, okay, and sometime you find children who have say, both edematous as well as non-idimiters malnutrition, okay, they have mixed malnutrition, so those are basically mixed, mixed SAM, okay, all right, so again here, I again, I just talked about this, acute malnutrition, moderate acute malnutrition and SAM, severe acute malnutrition, severe acute malnutrition, depending upon child has edema or does not have edema, it is divided into three types, non-idimiters SAM, edematous, edema means swelling and mixed SAM, okay, all right, here what we have done, we have just shown, and I will go again detail in my last session, so SAM basically is, basically you take, you know, growth chart which is WHO, and you look at the Z score, not the percentile growth chart, although I love percentile growth chart for individual monitoring, but to look at if the child is underweight or, you know, or stunted or for SAM, we look at Z score, so in the Z score basically, your weight for height is less than minus this standard deviation, okay, for SAM, Newark, mid upper arm circumference is less than 11.5 centimeter, okay, for 6 to 59 months of age, and if child has any presence of bilateral pitting edema, there is no other, you know, cause of that pitting edema, basically it is because of severe acute malnutrition, okay, this student may not be having, their weight might be okay because there is a lot of fluid collection, okay, and in MAM what you have is basically, when you look at the standard deviation growth chart, this student fall between minus to standard deviation and minus the, between minus 2 and minus to standard deviation, okay, and Newark is between more than 11.5 to less than 12.5 centimeter, okay, so that, so here I am going to discuss about type 2, so again in last presentation, in last session, I showed you, you know, what happens when you have typed in nutrient deficiency, you know, obviously, because type 2 is not stored in the body, it's part of your tissue, muscle tissue, your organ, you know, those are made up of your type 2 nutrients, so when you don't have type 2 in your food, then because it is part of so many metabolic functions, you know, so many enzymes, so it has to come from somewhere, otherwise, you know, child would die right away, so here, you know, your nutrient type 2 nutrients are coming from muscle mass, okay, so that's why muscles are melting, okay, so obviously child, this child would be under weight, they would have Newark, which is much, you know, smaller than 11.5, and also if it continues for a long time, you said child survives, then it would, child would have growth failure in a sense, child will have, you know, less height or less length, okay, so that's the important aspect, when it is, when it goes on for a long period of time, as I mentioned, they will become short, okay, so this is all, this are about the same age children, and look at the height difference, similarly, you know, this is a picture from Guatemala, and for, you know, nine years old, supposed to be here, but they all are short means, obviously, they haven't got type 2 nutrient for a long time, okay, so again, what is acute malnutrition? Short-term nutrition problem, primarily type 2 micronutrient deficiency, okay, it could be because of lack of food, sudden lack of food, in rainy season, or in any, you know, pendant, or any of those, sudden weight loss, signs, yeah, you're thin, you know, see really wasted or any mattress, we don't call it marasimus or kosher curd, I've just kept the name, so that, you know, people who have learned this marasimus and kosher curd, they would, they would be able to relate to it, but what we were taught is that, you know, marasimus is mainly, you know, edematous SAM, and it was marasimus, what we were told was a calorie deficiency, so children were thin, but we don't call that anymore, we don't call marasimus as, you know, or kosher curd, and kosher curd, what we were told was a protein deficiency. Now, child has lower weight than expected for that height, so in acute malnutrition, the weight kind of decreases remarkably, okay, so the, as per height child needs to have such an amount of weight, but because child has lost that weight, you know, child is wasted, okay, so that's called wasting. Chronic malnutrition is long duration of malnutrition, you know, failure to receive adequate nutrition for a long period of time, okay, they may have diarrhea on and off, on and off, they get better, but they don't get put on that weight, whatever they have lost, and slowly, slowly their height suffer, okay, they have growth failure, and they are called stunting. Now, here is example, so if you look at this child, this child is say normal, about 11-month-old babies, okay, this child, you can look at it, look at there, he looks thinner, so if you look at their muscle mass, see how thin it is, you can see his rib cage also, so this child is wasted, wasting, acute malnutrition, okay, height is a little bit low, but it's not that bad, okay, now look at this child, this child, you can see the muscle mass is good, it looks okay, but the height is okay, so this is called, this child is called chronic malnutrition, okay, and this child is basically acute malnutrition, this is acute malnutrition, this is chronic malnutrition, okay, similarly, same thing, you know, same child, this is the normal child, this is your wasted child, means, you know, look at the medium circumference, much smaller, right, your muscle is gone, okay, and this child now has now lost the height, because this child probably was like this on and off, on and off, not so bad, you know, but eventually his height has suffered. Now, if this child, chronically stunted child, develops some, say, diarrhea or bone or stop eating, and if this child gets acutely malnourished like this, where he loses a lot of muscle mass, that child at very high risk of developing any severe condition in which we can lose this child, you know, so mortality is very high in a child who has stunting as well as wasting, okay, so this is, this is of course, the example of, you know, a type 2 deficient rats, so, you know, rats which are type 2 nutrient deficient are much smaller than the rats which are, which are normally, okay, so, you can, you see similar kind of results even in plants, so in plants where you kind of put a lot of these nutrients, you know, phosphorus and all those minerals, you know, then you will see much better growth in those plants, while plants which does not have good amount of fertilizers, they won't grow as big at all. With this, I'm going to end part one of the session. We discussed about types of malnutrition and hidden hunger. Most of us have one or the other deficiency of vitamins, minerals, or any of those nutrients I discussed, so that's why we have created tutorials on recipes so that you know if you have any of those symptoms, you know, do think of, you know, one of those nutrient deficiency and then you can learn to cook and, you know, add those food, natural food, which can give you all those, you know, nutrients which are required for you to maintain your health and also to maintain your, you know, immunity, resistant power, you know, to prevent you from chronic conditions. So I do kind of, you know, I do request you all to watch those tutorials. Thank you.