 like to welcome you to my first session, we will start the first session with NFHS-5 data which has just come out recently. This is to understand the problem of undinutrition in India ok. So, let us understand what data shows us, this is NFHS-5 data national family health survey ok. And basically here in the first slide what you are seeing is the age wise distribution of nutrition indicators ok. So, age wise in a sense that what we have done whatever data that NFHS-5 had we have kind of distributed among the different age groups ok. So, here in you have months 0 to 2 months, 3 months, 4 to 5 months of baby, 6 months ok. And here you have a percentage on a y axis. So, here we have taken 3 indicators for example, blue is your wasting, your yellow line yellow bar is your underweight and red one is your stunting ok. 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 percent children who are wasted ok, almost 30 percent. 30 percent children are underweight and about say 28 percent are stunting. That means, right at births and then in first 2 months almost your 1 third children are not doing well ok, 1 third children that is a huge lot of number. Now, when you you know that in first 2 months what matters mother's nutrition during pregnancy and your breastfeeding ok. That means, our mothers are not getting enough nutritious rich food. So, babies are of course, grown low birth weight and also even if they are probably growing well, but because probably the latching on the milk transfer is not good from mothers to babies ok. And that is why you know you need to have a good amount of catch up growth and maximum occurs in first 2-3 months of age you know and that is not occurring ok. So, not only there is a tremendous amount of growth faltering occurring in first couple of months, but also growth catch up is not occurring ok. So, this is very very important to understand that first 2 first 0 to 2 months of age a lot of these babies are you know not not doing well. Looking at 3 month age data again if you look at your wasting, wasting from say around 29 percent has gone down to maybe 26 percent not much decrease in wasting ok and your underweight pretty much stays same ok. There is little bit of stunting decreasing which is good, but then let us go back to again 4 to 5 months of age and then look at again the wasting has not decreased much, underweight has not decreased much and stunting stays as it is ok and that is the same trend that you see in 6 months of age babies also. So, what we are saying is that in first 6 months of age where there should be tremendous amount of growth catch up occurring, there should be almost 0 growth faltering occurring should be occurring, but probably we are getting lot of growth faltering very poor growth catch up ok. Now, this again up to 6 months is all breastfeeding ok nothing as so, of course, milk transfer is a problem, problem many mothers are giving cow's milk and babies are getting diarrhea ok. So, we have to also consider that starting from 7 to 12 months of age now this age group if 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 ok. So, if you look at it there is little bit of improvement in wasting, but look at the underweight and stunting going up ok. This means that babies who are already malnourished in first 6 months they are becoming much more malnourished because there is no proper support of complementary feeding in this age group ok. So, now, you can see how all your underweight as well as your stunting going up ok, very very crucial stage we have seen many babies who grow beautifully on mother's milk till 6 months of age, but if mother is not supported on how to give complementary food they become thin you know they lose lot of weight and they become thin ok. And then let us go to 1 to 2 years of age now in 1 to 2 years of age what you see is basically now look at the stunting literally from 0 to 2 months you had about 28 percent now it is almost reaching to 40 percent ok. But significantly high number of stunting at between 1 to 2 years of age this means that completely the failure of first year of life when it comes to IYCF ok. IYCF is your maternal infant, young child nutrition, so not only maternal nutrition has gone wrong, but also your breastfeeding has gone wrong and also your complementary feeding rate has gone up. So, it is basically ongoing chronic condition and that is when you see remarkable increase in stunting as a baby is getting stunted obviously, baby's bones are small. So, now you have underweight also you know short baby is always kind of way underweight unless child puts on lot of fat ok. So, this is important that you know there is significant reduction or I would say significant increase in stunting and underweight ok. As stunting increases you can see wasting decreases ok. Now, this in my opinion is that as baby is becoming shorter and shorter you know your wasting is getting masked ok, because that shorter baby does not need to have that much weight to not come under wasting graph ok. So, that is why this is paradox as the stunting goes up the wasting comes down, but this is masking of wasting ok. Then comes your 2 to 3 years of age, in 2 to 3 years of age you can again see not much decrease in stunting look at the underweight going up you know it has gone up now from 30 to 31 percent to almost 34 percent ok. And again not much decrease in wasting similarly in this graph you can see that you know from 3 to 6 years of age actually 5 years of age 3 to 5 years of age you can see pretty much the same graph again stunting and underweight pretty high and then your wasting is kind of you know lingering around 16 to 17 percent ok. So, this age wise change in your underweight wasting and stunting is very important to understand, because once you understand the data you will understand the root cause and then you will be able to give the good solution ok. So, I am going to come to another bar graph this is under nutrition in India according to residents, residents in a sent urban or rural area ok. So, here if you look at stunting data obviously, stunting in you know your rural area is much higher than your urban area ok, pretty much same thing for underweight also wasting not much difference. So, in wasting your urban or rural area has equal number of wasted children underweight and stunting yes, because of course, as child is stunted child is going to vendor weight because bones are small ok. This is as per gender so, as per gender you can see that males are little bit higher when it comes to stunting and underweight wasting is not much difference, but little bit of just minor difference, but again you know males are at disadvantage you know normally what you would see that you know in India especially you will see girl children being more you know underweight and of course, wasted and stunted, but it is nature is protecting this girl child, because eventually she is going to bear a baby you know so, she is protected not that I am saying too much of protection, but it is probably nature's way of protecting a girl child ok. We need to work on all these indicators understand the root cause understand the issue and then we can definitely kind of understand the you know solution and we will come with excellent results. Now, this is another very good pie chart again under nutrition prevalence among children below 5 years of age ok. So, see out of 100 percent about 47.8 percent are absolutely normal when it comes to wasting, stunting and underweight ok. So, that is pretty low number actually you want almost 96 percent children to be in this category all normal, but you have only 47.8 percent which is almost half ok. Here what we have what we have done is basically we have seen we have taken data of babies children under 5 years of age who are only stunted ok, only stunted no underweight and no wasting also you. So, you have about 15 percent children who are only stunted, only wasted children children who are only thin wasting was thin you know child is thin right. So, only wasted children about 6.5 percent only underweight children are 2.3. So, that is a very low number generally underweight is usually associated with either wasting or stunting very rare to have you know underweight and this other children probably you know might have just had one or the two acute infection and suddenly weight has gone down, but not gone down as much that it shows up on wasting graph ok. About there is 0 percent babies who are only stunted and wasted ok. So, 0 percent in that and when it comes to stunting and underweight the reason you have only 0 percent stunting and wasting because stunting and wasting is always associated with underweight ok. So, you want to remember that that whenever you have a stunted child and wasted child child has to be underweight and that is why showing 0 percent not if you do not include underweight ok. When you have a stunted child and underweight child about 15 percent children are stunted and underweight ok. Now, this children probably with a Sam is masked because child is short and this child is short you know child is also underweight ok that significant number 15.5 percent children are stunted and underweight ok. Now you have underweight and wasted. So, you have about 7.5 percent children who are underweight as well as wasted ok. So, these are the children probably child is doing metabolically really well means child has stunting child does not have stunting, 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 percent children are wasted and underweight ok. And if you look at all the three indicators which includes your stunting, wasting, underweight you have about 5.2 percent children who have all three indicators and this are the children who are at very high risk of a lot of complications ok because you have this chronically malnourished child who is stunted now is becoming wasted ok. So, of course, mortality also increases in this children ok who are stunted and you are wasted ok. So, this is another very important graph which is important to understand ok. Now, let us talk about the prevalence of stunting ok. Stunting means your child children are short ok. So, this is again you have the graph of India in front of you this is Bihar. So, you can see that in Bihar you have very high stunting rate almost you can look over here. This is your India stunting level which is about 36 percent, 36 percent children are stunted in India. And if you look at last few states you can see Meghalaya, Bihar, Uttar Pradesh, Kharkhand, you know Dadara, Nagar, Haveli. This are some of the states which are kind of doing even Gujarat in fact if you look at Gujarat Gujarat is doing worse when it comes to stunting level ok. And here again this are all the states that we have shown here is your Meghalaya, this is your Bihar you know and this are data which is showing more than 40 percent ok. And then between 30 to 39 percent it is all your red zone. So, basically pretty much the whole of India has more than 30 percent you know stunting rate which is significantly high. As I mentioned to you we want only maybe 2 to 2.5 percent children who are who should be or who may be less than minus to standard deviation. But instead of having 2.4 to 2.5 percent children being stunted we have significantly you can see the whole of India is pretty much 30 percent and about ok. Let us talk about Underweight. Underweight is also average underweight in India is about 32 percent. But if you look at all the states you know again pretty much the same states that you know I mentioned for stunting which is your Bihar, Gujarat, Jharkhand, Dadara, Nagar, Haveli, Damandu you know Maharashtra many many states are not doing good compared to India. Of course, India by itself is not doing well when you have 32 percent underweight that is pretty significantly high actually ok. States which are doing reasonably well I would say reasonably well compared to India standard not necessarily for world standard you have a couple of states you know few states from northeast your Mizoram, Sikkim, Manipur. Puducherry is doing pretty good compared to India and also Arunachal Pradesh and Punjab. Here you can see again pretty much same you know states you can see red all the red areas are all underweight about 30 percent ok. Not that we want 20 to 29 percent children underweight but you know just compares into to India standard ok. Now this is wasting wasting waste acute malnutrition so your Sam, Ma'am comes under wasting ok your thin like Asper height what is the weight of the child ok so again if you look at it average wasting in India it's about 19 percent you know so there are many states which are worse than India standard ok and that's you again see pretty much you know your Maharashtra, Gujarat, Bihar, Jharkhand, Assam, Tilangana, you know Dhadar, Nagarhavilli, Damanandu so this all basically not doing well here is your you know again your red areas wasting is pretty significant. Now suppose if child is doing very well if child is growing well in terms of height and if suppose child for couple of days or few days hasn't eaten because of some diarrhea pneumonia you definitely want to treat those infection but they come out pretty fast ok if the metabolism is very good 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 you know they were chronically malnourished when they got diarrhea it got very difficult to bring the child out of wasting ok so you want to make sure that you're just you know that longitudinal data is more important than the cross sectional data in wasting ok so cross sectional means you know you just measure weight for height even say once once and tell you know tell that oh this child is wasted generally I prefer that we have a longitudinal check up so child is growing well you know height child height wise child is growing well over period of time sometime when they have again infection they would get thin they would lose weight but again those shouldn't come out very fast when you treat infections ok so that's important you can see some of the economically advanced state 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 just looking at the wasting data I you know I won't comment you know we have to also look at 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 and child malnutrition ok now let's look at anemia this is your urban area rural area total anemia any anemia so you have different kinds of anemia so any anemia almost 65 percent children are anemic ok total of course higher in rural areas when you look at mild moderate and severe anemia again you know you have basically almost 30 percent children who come into mild category moderate category you have about you know about 35 percent children in rural areas and about 32 percent children in urban areas and severe anemia almost 2 to 3 percent children are severely anemic ok and total any anemia means mild moderate severe so if you calculate all three of them together you know just randomly take any child who is you know anemic that number is significantly high ok and unfortunately what happens when you are diagnosed with anemia and say nine months to one year of age those babies are already kind of have poor IQ because once you diagnose that means anemia has already kind of caused impact on their brain because you need good amount of oxygen going to child's brain because brain is growing very fast so this one is really crucial that we prevent anemia ok not of course we have to treat this anemia children also but again mother's milk and complementary food which is high in iron the counseling is very very important for mothers ok here you are looking at anemia among children in India according to gender so if you look at gender again you know in young children up to five years of age there is not much difference ok this of course girls children are not menstruating so they are not losing blood so this is all basically diet related anemias ok and here you can see both boy and a girl child almost 65 percent children are anemic ok not much difference gender wise when you look at you know the graph of India this is again you can see almost 60 percent children are anemic ok so we want to make sure that you know we we give again nutrition counseling is very very important six almost look at the 65 percent children anemic the dark is almost reaching 90 to 92 percent so the dark you know we need to kind of really intervene in the dark Gujarat also lord the states again same the other are going to really demand you you know this all states you know that we can basically work on to improve anemia ok this is status of key breastfeeding practices and if I just five so if you look at what are your breastfeeding indicators ok breastfeeding indicators is early initiation of breastfeeding and your exclusive breastfeeding rate ok so you look at early initiation of breastfeeding now we know that institution delivery has gone really high up you know on more than 90 percent deliveries occur in institution institution but look at the number of children who are given breast milk in the hospital within one hour ok very poor 40 percent only ok urban maybe around 40 to 43 percent but rural areas 40 the total comes out to be 41 42 percent not more than that ok so here we can really improve this 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 give breast milk within one hour that colostrum is extremely important to develop good immunity gut microbiome ok to prime that baby it's like you know when we take vaccine so when you when you vaccine with the baby you're basically priming that baby for infections in the future right similarly when you give breast milk first thing immediately as soon as baby is born that colostrum has you know 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 ok so very very crucial that you work on this early initiation of breastfeeding another thing is ever breastfed child who receive prelactal feed means babies who get say something other than breast milk ok so very significant number of children they get prelactal feeds you know you can see it almost 20 percent children are getting prelactal feeds which is something other than breast milk ok what is the status of breastfeeding practices again if you look at the region wise so all these areas you can see all this red zone only early initiation of breastfeeding is only between 12 to 40 percent which is which is significantly poor you can see in India on only 42 42 percent of children are getting early initiation of breastfeeding many areas they are have early initiation of breastfeeding your Meghalaya has good amount of early initiation of breastfeeding Lakshwadeep, Odisha, you know Kerala right some of these areas like Jharkhand, Uttar Pradesh, Damandu, Tadarnagar, Availi, Bihar these are the areas that we saw they are not doing well when it comes to nutrition indicators and they are not even getting breast milk in first five first half an hour or so you know half an hour to one hour ok so you want to improve though in those states you definitely want to improve your early initiation of breastfeeding if you look at exclusive breastfeeding look at the exclusive breastfeeding rate in India is about 63 to 64 percent many mothers around 75 percent of the mothers they start exclusive breastfeeding they want 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 this is absolutely not needed so this is also for pediatrician to please kind of start a breastfeeding exclusive breastfeeding at both as well as up till six months of age ok and again not much difference when it comes to urban rule a rule exclusive breastfeeding rate is a little bit higher than urban area again if you look at exclusive breastfeeding rate in India you know many states which are giving exclusive breastfeeding rate I mean exclusive breastfeeding to babies but they are not doing well when it comes to nutrition indicators ok. So, you Chhattisgarh, Dadar, Nagarhaveli, Damandu, Jharkhand you know a MP although they are giving good amount of exclusive breastfeeding rate but your nutrition indicators are not good that means milk transfer is not occurring ok. So, in my opinion only looking at exclusive breastfeeding rate is not enough you have to look at early effective and exclusive. So, I strongly believe in triply early effective and exclusive breastfeeding rate ok. Now, so other feeds like what are the other feeds that children are getting you know so many of this so your blue is your plain water so many babies almost 4 to 5 percent babies are getting plain water literally under two months of age they are also getting non milk liquid so they are getting either honey, good tea or any of those and other milk which is probably a cow milk formula and your complementary food. So, many babies are being given complementary feeding in by less than two months of age ok. You do not want all this thing because there is a high risk of infection and children will not grow well and as you can see as child is growing older you know your plain water intake is increasing complementary feeding rate is also increasing your other milk intake is also increasing ok. So, this particular graph is very very important ok status of complementary feeding 6 to 8 months as per resident. So, again you know around 52 percent children in urban areas are getting you know complementary feeding by 6 to 8 months of age and rule as is much less ok. This is about complementary feeding at 6 to 8 month again lot of the states in red zone are not getting complementary feeding by 6 to 8 months of age. So, the states need to improve remarkably again your UP Rajasthan, Jharkhand, Bihar you know this the states you know states in the middle are not doing very well ok. This is minimum acceptable diet. So, minimum acceptable diet is your dietary diversity, your frequency and your both together is your minimum adequate diet. So, again in India breastfed babies and even non breastfed babies only 10 to 11 percent babies are getting minimum adequate diet that means, enough frequency and enough dietary diversity ok. So, can you imagine only 10 percent to 12 percent babies are getting proper complementary food under you know 2 years of age. If this children do not get proper complementary food believe me they are going to become wasted they are going to become under weight stunted ok. So, this is important again this is age wise category of your minimum adequate diet, MAD I will focus on MAD which is a minimum adequate diet which includes your frequency as well as your dietary diversity ok. So, very very poor uptake of complementary feeding up to 2 years of age as you can see age wise it is pretty poor ok. Thank you so much as now we understood an FHS5 data very well. Let us see what in next session I am going to talk about what exactly we did in urban slums in other areas of India to improve this indicators in the small of course small program, but in those small program we learnt lot of you know loopholes and how to kind of come up with solutions to manage this malnutrition among those underprivileged children ok. Thank you.