Comprehensive National Nutrition Survey 2016 18

A presentation on the comprehensive national nutrition survey

1. Comprehensive National Nutrition Survey 2016-18 Resource faculty: Prof. Vijay Kumar Tiwari Dean & HOD P&E dept, NIHFW Presenter: Dr. Dipayan Banerjee DHA – II, NIHFW

2. Contents Background of CNNS Justification of study Gaps identified in CNNS Scope of the seminar Survey methodology Determinants of child nutrition Findings Infant and young child feeding Double burden of malnutrition Micronutrients Limitations of CNNS data Major issues identified Recommendations

3. The CNNS was funded through a generous grant from Aditya Mittal, president of Arcelor Mittal, and Megha Mittal, Managing Director of ESCADA

4. Problems of Malnutrition Nearly half of all deaths in children under five years linked to poor nutrition Stunting in early life can have long-term effects on health, physical and cognitive development, learning and earning potential. At least 10% child in the population suffers from one or more micronutrient deficiency Every third adolescent girl and every fourth adolescent boy 10-19 years is too short for their age. 5% adolescents 10-14 years and 4% adolescents 15-19 years are overweight.

5. Undernutrition Status

6. Cost of malnutrition Adults who are undernourished like children earn at least 20% less wages Undernutrition and micronutrients deficiency costs around $2.1 billion per year Child and maternal malnutrition are by far the largest nutrition related health burden in the world Cost of treating obesity/overweight costs 4-9% of country's GDP Cost of NCD treatment due to obesity costed to $1.4 trillion in 2010 Malnutrition in first 2 years of life decreases education potential Asia and Africa losses 11% of it's GNP yearly due to poor nutrition

7. Cost Benefits of proper nutrition Cost benefit analysis of investment on proper nutrition gives a return of 18:1 per child With adult height, with 1 cm increase in stature is associated with 4% increase in wages in men and 6% in women

8. Burden Of Malnutrition In India

9. Topics covered in CNNS 1. Micronutrient deficiencies in pre-school, school-age children and adolescents 2. Causes of anemia in children and adolescents including assessment of haemoglobinopathies 3. Biomarkers of non-communicable diseases in school-age children and adolescents 4. Representative data on health and nutrition for school-age children 5–9 years and young adolescents 10–14 years of age 5. Characterization of anthropometry related to undernutrition or overweight / obesity

10. Scope of seminar To assess the extent and severity of micronutrient deficiencies among children and adolescents To assess the status of visible malnutrition in the children and adolescents To assess the status of the feeding and diet of infants and young children To estimate the prevalence of dual burden of malnutrition in children and adolescents using a comprehensive set of established anthropometric measures To assess the extent of stunting/wasting/underweight/overweight in children and adolescents in different states of India

11. Survey Methodology

12. Survey Participants 112,316 children and adolescents interviewed with anthropometric measures collected Blood, urine and stool samples drawn from 51,029 children and adolescents 2,500 survey personnel in 30 states  200 trainers and coordinators  900 interviewers  360 anthropometric measurers  360 survey supervisors and quality observers  100 data quality assurance (DQA) team members  360 phlebotomists  200 laboratory workers  30 microscopists

13. Sample Size At the national level, the planned sample was calculated to be 122,100 children and adolescents from 2035 primary sampling units (PSUs) across the country. The planned sample size was 40,700 individuals in each of the three age groups for the household survey and anthropometric measurements and 20,350 individuals for biological samples for each of the three age groups.

14. Selected Districts and PSUs

15. Sample design The first stage was the selection of PSUs using probability proportional to size (PPS) sampling and the second stage was a systematic random selection of households within each PSU In large PSUs, additional segmentation procedure is done to reduce enumeration areas to manageable sizes. To ensure representation of different socioeconomic groups in the sample, a stratified sampling procedure was adopted at the first sampling stage in rural areas

16. Survey Tools

17. Inclusion Criteria Individuals in selected households were eligible to participate in the survey if they: i) were between 0–19 years of age ii) were usual residents of the selected household iii) consented/assented to participate in the survey

18. Exclusion Criteria Individuals in selected households were not eligible to participate in the survey if they: i) did not fulfil the above-mentioned inclusion criteria ii) had a major physical deformity (e.g. paralysis, cerebral palsy) or cognitive disabilities iii) had an acute febrile or infectious illness iv) had a known chronic systemic illness including tuberculosis, cancer, liver disease and renal disease v) were on medications for chronic illnesses vi) had an acute injury vii) were pregnant

19. Quality Assurance Of Household Interviews Internal monitoring and supervision Three-tiers of monitoring for data quality assurance - monitoring was conducted by quality control observers and zonal/state field managers - three-member data quality assurance team and computer-assisted field editing (CAFE) software - experts from PGIMER, UNICEF and Population Council

20. Anthropometric measurements

21. Quality Assurance Of Anthropometric Measurements Internal monitoring and supervision Three-tiers of data quality assurance - quality control observer in the field team and zonal/state field managers - a three-member data quality assurance team in each state - experts from the PGIMER, UNICEF and Population Council.

22. Biological Sampling For biological sample collection, two out of three children among 5–9 years and 10–19 years were selected using systematic random sampling . All children aged 1– 4 years were selected for biological sample collection. Blood, urine and fecal samples were collected to estimate the prevalence of micronutrient deficiencies, subclinical inflammation and parasitic infections . Blood pressure was measured for adolescents aged 10–19 years.

23. Quality Assurance Of Biological Samples All laboratory testing equipment was validated daily or weekly against internal standards. Three levels of quality assurance were implemented: - First, an internal quality control sample was used for each batch of 20 survey samples. - Second, for external quality assurance , a subset of samples was sent to other participating laboratories monthly for comparison testing. - Third, on a weekly basis, a percentage of samples were split and reanalyzed as a third quality control measure. - Lastly 5% of the survey samples were randomly selected and sent to the National Institute of Nutrition (NIN) and AIIMS laboratories for additional quality control testing.

24. Findings

25. Determinants of Child Nutrition Morbidity and mortality in childhood --- Decrease Cognitive, motor, socio emotional development ---Increase School performance and learning capacity --- Increase Adult stature --- Increase Obesity and NCDs --- Decrease Work capacity and productivity --- Increase

26. Variables

27. Key findings Thirty-one percent of mothers of children aged 0–4 years, 42% of mothers of children aged 5–9 years, and 53% of mothers of adolescents aged 10–19 years never attended school Less than half of mothers of children and adolescents were exposed to any mass media in 5/9 Empowered Action Group (EAG) states (Assam, Bihar, Jharkhand, Rajasthan, Uttar Pradesh) and Meghalaya The majority (~ 80%) of respondents were Hindus, followed by Muslims (16%), Christians (3%) and Sikhs (1%) More than 50% of adolescents in Bihar, Jharkhand and Madhya Pradesh were from poorest wealth quintile households

28. Infant and young child feeding and diets Early initiation of breastfeeding Exclusive breastfeeding and continued breastfeeding at age one year Complementary feeding Minimum dietary diversity, meal frequency, and acceptable diet Food consumption among children aged 2–9 years and adolescents aged 10–19 years

29. Key Findings 57% of children aged 0–24 months were breastfed within one hour of birth 58% of infants under age six months were exclusively breastfed 83% of children aged 12 to 15 months continued breastfeeding at one year of age Timely complementary feeding was initiated for 53% of infants aged 6 to 8 months While 42% of children aged 6 to 23 months were fed the minimum number of times per day for their age, 21% were fed an adequately diverse diet and 6% received a minimum acceptable diet More than 85% consumed dark green leafy vegetables and pulses or beans at least once per week

30. Anthropometric Status Measures of undernutrition, overweight and obesity Stunting, wasting and underweight among children aged 0–4 years Acute malnutrition measured by MUAC among children aged 6–59 months Overweight measured by WHZ, TSFT, and SSFT among children aged 0–4 years Overweight and obesity as measured by BMI-for-age among children and adolescents aged 5–19 years

31. Percentage of stunting among children aged 0–4 years

32. Percentage of wasting among children aged 0–4 years

33. Percentage of underweight among children aged 0–4

34. Percentage of overweight among adolescents aged 10–19 years

35. Double burden of malnutrition

36. Micronutrients The prevalence of vitamin A deficiency was 18% among pre-school children, 22% among school-age children and 16% among adolescents Vitamin D deficiency was found among 14% of pre-school children, 18% of school-age children and 24% of adolescents Nearly one-fifth of pre-school children (19%), 17% of school-age children and 32% of adolescents had zinc deficiency The prevalence of vitamin B12 deficiency was 14% among pre-school children, 17% among school-age children and 31% among adolescents

37. Nearly one-quarter (23%) of pre-school children, 28% of school aged children and 37% of adolescents had folate deficiency Adequate iodine status (median urinary iodine concentration  100 μ g/L and  300 μ g/L) was observed in all three age groups - 213 μ g/L among pre-school children, 175 μ g/L among school-age children and 173 μ g/L among adolescents Children and adolescents in all states, except Tamil Nadu had adequate levels of urinary iodine concentration. The estimate from Tamil Nadu showed the urinary iodine concentration was just at the lower limit of excess intake (median ~320 μ g/L)

38. Vitamin A deficiency

39. Vitamin D deficiency

40. Zinc deficiency

41. Limitations On Use Of CNNS Data CNNS is a cross sectional survey . The data cannot be used to conduct analyses of causality. It provides information on the associations between indicators and outcomes. CNNS sampling and sample size was designed to present results at state level . Analysis below the state level will not be statistically representative. Disaggregated analysis , for example by socio-economic status of CNNS biochemical indicators at state level cannot be done due to limitations in sample size. The timing of CNNS data collection varies by states. Indicators affected by seasonality should be compared and interpreted with caution.

42. Major issues identified At least 10 % of the children and adolescents have deficiency of some kind of micronutrients The dual burden of the malnutrition is maximum among the children aged 0-4 years The burden of overweight children are maximum in Tamil Nadu whereas Jharkhand has maximum number of underweight children

43. Jharkhand also has maximum burden of wasting and stunting is maximum in the states like Bihar and Meghalaya. Only 57% of newborns in India were initiated breast feeding in first hour of life and this practice is mostly affected by the education of mother. Higher prevalence of stunting in under-fives was found in rural areas compared to urban areas. Also, children in the poorest wealth quintile were more likely to be stunted, as compared to 19% in the richest quintile

44. Recommendations Early initiation of breastfeeding and exclusive breast feeding needs to be improved nationwide with better counselling during ANC visits and institutional delivery The currently running programs on malnutrition like the National Nutrition Mission and School Mid Day Meal schemes should be strengthened The state needs to identify the locally grown nutrient rich food products and increase awareness among the locals about their consumption and benefits Food fortification for vitamin B12 and zinc can be considered by FSSAI and FFRC An supervising officer may be appointed for monitoring and evaluation of smooth running of the nutrition programmes.

45. References https://nhm.gov.in/WriteReadData/l892s/1405796031571201348.pdf Almost all the data in the presentation are taken from the official research data of CNNS published in the website of NHM