1. National Family Health Survey-2 1998-99 Bihar
Nutrition
This presentation presents information about the nutrition of women and young children in Bihar

2. Contents of Presentation
Food Consumption
Nutritional Status of Women and Children
Infant Feeding Practices
Anaemia Prevalence
1. We will look at both the types of foods consumed, as well as the consequences of inadequate nutrition and poor feeding practices for women and children.
2. NFHS-2 contains more comprehensive information on these topics, and, for the first time, included:
(i) anaemia testing for women and young children, and
(ii) Testing of cooking salt used in respondents’ homes to determine the extent of iodization...
Click for arrow………………..
Starting with food consumption patterns among women of reproductive age (15-49 years)…
National Family Health Survey - 2

3. Items Women Consume at Least Once a Week
1. First, we know that consumption of a wide variety of nutritious foods is vital for women’s health, and that adequate amounts of protein, fat, carbohydrates, vitamins, and minerals are essential for a well balanced diet. NFHS-2 asked the sampled women how often they consumed various types of foods, whether daily, weekly, occasionally, or never.
2. As this graph shows, the most common food items consumed by Bihari women at least once a week are both green, leafy vegetables, as well as other vegetables. A high proportion of women also consume pulses and beans at least once a week.
3. In contrast, only 22% of women stated that they consumed non-vegetarian foods at least once a week, including chicken, meat, fish, and eggs. An even smaller proportion stated that they consumed fruits (18%).
Table 7.2, p. 161
Percent
Percent
National Family Health Survey - 2

4. Women’s Consumption of Milk/Curd
Occasionally
45%
Daily 21%
1. When we look at patterns of consumption among women for all food groups, several interesting characteristics are revealed.
2. First, less than a quarter (21%) of women eat milk or curd daily, and one-quarter (25%) stated that they consume these foods weekly.
3. Thus, about half of the women in Bihar either never consume milk or curd (9 %) or consume it only occasionally (45%).
Table 7.1, p.160
Weekly
25%
Never 9%
National Family Health Survey - 2

5. Women’s Consumption of Chicken/Meat/Fish
Never
13%
Occasionally
65%
Daily 1%
1. Similarly, more than three-quarters of women in Bihar either never eat chicken, meat, fish, or eggs, or consume them only occasionally.
2. A fifth (20%) eat these items on a weekly basis….. and just 1% every day.
Table 7.1, p. 160
Weekly
20%
National Family Health Survey - 2

6. Women’s Food Consumption Differs by Standard of Living
Percent (at least weekly)
Milk/Curd
Fruits
1. As expected, poverty has a strong negative effect on the consumption of nutritious foods, such as milk or curd or fruits.
2. This chart shows how consumption varies strongly with income levels. Women from households with a low standard of living, which are the green bars to the left, are less likely to eat milk or curds or fruits than those with higher incomes
3. It should be noted, however, that only about half (51%) of women from even high income levels eat fruit at least once weekly.
Table 7.2
Low
Medium
High
Low
Medium
High
National Family Health Survey - 2

7. Contents of Presentation
Food Consumption
Nutritional Status of Women and Children
Infant Feeding Practices
Anaemia Prevalence
1. Next………….click yellow arrow…………….. we turn to the nutritional status of women and children in the sampled households.
National Family Health Survey - 2

8. National Family Health Survey - 2
Measuring Equipment
Solar-powered digital scale with an accuracy of ± 100 grams
Adjustable wooden measuring board specially designed for use in the field (accurate to nearest 0.1 centimetre)
1. For the purpose of accurate measurement, NFHS-2 included two pieces of measuring equipment: a solar-powered digital scale for weight measurements that is accurate up to plus or minus 100 grams……………… and an adjustable wooden board for height measurements that is accurate to the nearest 0.1 centimetre.
2. These height and weight data were used to estimate a number of indicators of women’s and children’s nutritional status, as we shall see in a moment…………..
National Family Health Survey - 2

9. National Family Health Survey - 2
Women’s Height
Standard “nutritionally at health risk” height is less than 145 cm, with a range of cm
NFHS-2 mean height for women in Bihar is 150 cm
20 percent of women in Bihar are nutritionally at health risk
1. Typically, the cutoff point for height below which women may be identified as being “nutritionally at health risk”, is 145 cm.
2. In Bihar, average height is 150 cm………….but as much as 20 percent of women were found to be below 145 cm. in height and, therefore, nutritionally at health risk.
3. As may be expected, short stature is also strongly related to poverty. While one in every four women living in households with a low standard of living was found to be at health risk, only one in every 11 women from a high standard of living household could be similarly classified.
[Note- This risk factor varies marginally by region. Although in all 3 regions the proportions are high…North Bihar has 18%, Jharkhand 19%, and South Bihar 22%.
Source: Table 7.3, p. 162
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10. National Family Health Survey - 2
Body Mass Index (BMI)
Definition: Weight in kilograms divided by height in metres squared (kg/m2)
Chronic energy deficiency if BMI less than 18.5
About two-fifths of Bihari women (39%) have chronic energy deficiency
Body Mass Index as defined here is the weight in kilograms divided by the height in metres squared. Any measurement less than 18.5 is considered chronic energy deficiency.
Based on this measure, nearly two-fifths of women (39%) were found to be energy deficient in Bihar. Let’s look at where Bihar ranks in terms of this indicator vis-à-vis other states in the Union.
Source: Table 7.3, p. 162.
National Family Health Survey - 2

11. Percent of Women With Chronic Energy Deficiency by State
This slide presents a statewide comparison of chronic energy deficiency showing some of the high and low states.
1. We see that the chronic energy estimate for Bihar at 39% is only slightly higher than the all-India average of 36% percent of women...
2. As may be seen, Bihar ranks with states that have high proportions of energy deficiency such as Rajasthan, Madhya Pradesh, Maharashtra, West Bengal and Orissa, as compared to states such as Punjab and Delhi where the percents are 17 and 12 respectively, and Arunachal Pradesh with 11 percent.
3. In fact, Bihar is the fourth highest ranked state.
4. Nutritional deficiency is particularly high for rural women (40%), women in the Jharkhand region (41%), illiterate women (43%), and women from households with a low standard of living (45%).
Source: Table 7.3 for M.P.; Table 7.5 from National Report for All-India data.
National Family Health Survey - 2

12. Indices of Children’s Nutritional Status
Height-for-age (stunting): measure of “chronic” undernutrition
Weight-for-height (wasting): measure of “acute” undernutrition
Weight-for-age (underweight): composite measure of both “chronic” and “acute” undernutrition
1. Nutritional status is a major determinant of the health and well-being of children.
2. This slide shows the three key indicators used by the NFHS-2 team to assess children’s nutritional status. Once these were calculated they were compared to the values for those indicators compiled on an international reference population by WHO.
3. Each of these indicators provides slightly different information about the nutritional status of children, but all are indicators of undernourishment.
4. The height-for-age indicator measures linear growth and whether it has been retarded; thus the proportion of such children are considered stunted or short for their age.
5. The weight-for-height indicator examines body mass in relation to body length; these children are considered to be wasted, or too thin.
6. Weight-for-age is a composite measure that takes into account both chronic and acute undernutrition; children classified as such are considered to be underweight.
National Family Health Survey - 2

13. Malnutrition Among Children
Percent
As see here, more than half of all children in Bihar are underweight (weight-for-age) at 54 percent, indicating the effects of both chronic and acute undernutrition.
2. A similar percentage are stunted (height-for-age) at 54 percent, indicating the widespread prevalence of chronic undernutrition from a failure to receive adequate nutrition over a long period of time, or from chronic or recurrent diarrhea.
3. Wasting is also quite evident affecting 21 percent of all children in Bihar. This is an indicator of acute undernutrition, implying that these children failed to receive adequate nutrition in the period immediately prior to the survey, possibly due to seasonal variations in food supply, or recent episodes of illness.
Source: Table 7.9, p. 174.
Children under age 3
National Family Health Survey - 2

14. Underweight and Severely Underweight Children (NFHS-1 and 2)
Percent
1. But have things changed in Bihar since the last NFHS survey in 1993?
2. This slide shows the estimates of underweight and severely underweight children for Bihar for both NFHS-1 and 2.
3. As can be seen, the situation for underweight children under age 3 has improved with the proportion declining from 63% to 54% in NFHS-2.
4. Similarly, the proportion of severely underweight children has also declined from 32% to 26% over this period.
Source: Table 7.9 for Bihar;
Adjusted table for NFHS-1 (to change denominator to less than 3 years of age)
Children under age 3
National Family Health Survey - 2

15. Percent of Children Underweight by State
Looking across selected states, Bihar has one of the highest percentages of underweight children in the country at 54%
2. Other states with half or more of children underweight include Madhya Pradesh, Orissa, U.P., Rajasthan, and Maharashtra…….. with Andhra Pradesh and Tamil Nadu representing moderate levels at 38% and 37% respectively………..and Nagaland and Sikkim representing the lowest end.
3. In general, undernutrition among children in Bihar is strongly related to maternal nutritional status and poverty. Thus, undernutrition is more common among children whose mothers height is below 145 cm. Or whose BMI is under Similarly, children from households with a low standard of living are 2-5 times more likely to be severely undernourished as children from households with a high standard of living.
Source: Table: 7.17 from the All India Report (Weight-for-Age, Percentage below, -2 SD), and narrative on p. 175 of Bihar report NFHS-2.
Percent
National Family Health Survey - 2

16. Percent of Children Underweight by Region
1. This slide presents a regional comparison showing the percent of children underweight across the regions of Bihar; the differences are marginal and the proportions are high.
The range runs from a high of 58 percent in the South Bihar Plain to 52 in North Bihar Plain.
Source: NFHS-2: Table p. 176
National Family Health Survey - 2

17. Malnutrition Is a Critical Problem
Over half of children under three years of age are underweight. This proportion is one of the highest in the country.
The proportion of underweight children declined from 63% in the early 1990s to 54% in NFHS-2.
In addition, the proportion of severely underweight children (26%) is the highest of any state in India, although it has declined from 32% since NFHS-1.
1. To conclude this section, let us remind ourselves of three key findings:
(i) Over half of children under three years of age are underweight. This proportion is one of the highest in the country.
(ii) The proportion of underweight children declined from 63% in the early 1990s to 54% in NFHS-2.
(iii) In addition, the proportion of severely underweight children (26%) is the highest of any state in India, although it has declined from 32% since NFHS-1.
National Family Health Survey - 2

18. Contents of Presentation
Food Consumption
Nutritional Status of Women and Children
Infant Feeding Practices
Anaemia Prevalence
1. In our third sub-section, we turn to an examination of infant feeding practices.
2. These practices are important for both mothers and their infants:
(i) Breastfeeding influences the period of postpartum infertility and through it, fertility levels and length of birth intervals
(ii) Early initiation of breastfeeding is critical since it prompts the release of oxytocins and reduces the risk of postpartum hemorrhage for the mother
(iii) Breastfeeding also improves the nutritional status of the child and reduces morbidity and mortality
(iv) Finally, the timing and type of supplementary foods introduced in an infant’s diet also significantly affect the child’s nutritional status.
National Family Health Survey - 2

19. WHO Feeding Recommendations
Breastfeed children for at least 2 years
No bottle feeding
Start breastfeeding immediately after birth
Exclusive breastfeeding for first 6 months
Introduce solid/mushy foods at 6 months together with breastfeeding
Let’s look at WHO’s recommendations:
Bihar is doing very well with the points that have been checked (the first two points): breastfeed children for at least 2 years; and no bottle feeding.
The last three continue to be challenges:
1.Start breastfeeding immediately after birth. Increased release of a hormone (oxytocin) that caused uterine contractions and helps reduces the risk of hemorrage. Plus, first breast milk, or milk that appears shortly after birth, which is called colostrum, should not be squeezed from the breast before feeding the child, because colostrum provides natural immunity.
2. Exclusive breastfeeding for first 6 months. Because it is often difficult to sterilize the nipple of a bottle properly, the use of bottles with nipples exposes children to an increased risk of getting diarrhea and other diseases.
3. ….And the third challenge, giving solid/mushy food from about six months on, is critical for meeting the protein, energy, and micronutrient needs of the child.
National Family Health Survey - 2

20. Duration of Breastfeeding
Median duration of any breastfeeding is more than 36 months
Median duration of any breastfeeding is about 12 months shorter in urban areas, as compared to rural
Boys and girls are breastfed for an equal duration, > 36 months
1. The median duration of breastfeeding in Bihar is 36 months or more, compared to the all-India figure of about 25.4 months.
2. The median duration of any breastfeeding is about 12 months shorter in urban areas as compared to rural.
3. Boys and girls are breastfed for equal durations, (36 months or more).
Source: Table 7.8, p. 172.
National Family Health Survey - 2

21. Bottle Feeding for Children Under 12 Months
Less than 13 percent of breastfeeding children in any age group are bottle fed
1. Bottle feeding has a direct influence on the mother’s exposure to the risk of pregnancy since it may reduce the amenorrheic period. Also, as previously mentioned, because it is difficult to sterilize the nipple, bottle feeding can also increase the risk of infections for children.
2. In Bihar, fortunately, bottle feeding is not widely prevalent. Less than 13 percent of breastfeeding children in any age group were bottle fed.
Source: Table 7.7, page 170
National Family Health Survey - 2

22. Initiation of Breastfeeding
Only 6 percent of newborns are breastfed within one hour of birth, and 21 percent are breastfed within the first day
42 percent of mothers do not feed the first milk (colostrum) to their infants
Although both WHO and GOI recommend initiation of breastfeeding immediately after birth, only 6 percent of newborns were breastfed within one hour of birth, and only 21 percent of newborns began breastfeeding within the first day of birth.
2. The percent of of mothers who began breastfeeding within one day of giving birth does not vary much by urban-rural residence, mother’s education, religion, standard of living, type of assistance obtained during delivery, or place of delivery. However, some differentials are notable: for example, in the Jharkhand region, 31 percent started breastfeeding within one day of birth, while 24 percent did in South Bihar Plain and only 14 percent did in North Bihar Plain.
3. And ………despite the benefits of consuming the first milk (colostrum), more than 2 out of every 5 mothers do not provide colostrum to their infants.
Source: Table 7.5, p. 168.
National Family Health Survey - 2

23. Are Mothers Following Exclusive Breastfeeding Recommendations?
Here is how children under the age of 4 months are fed:
Breast milk and supplements
17%
Breast milk only 55%
1. Only 55 percent of children under the age of 4 months are being exclusively breastfed.
2. A further 26 percent receive breastmilk plus water, and 17 percent receive supplements along with breast milk.
3. Also, we should point out, that as age increases, the proportion of children receiving supplements along with breastmilk increases from 24% for children age 4-5 months to 85% for children age months.
Source: Table 7.6
Not breastfeeding 3%
Breast milk and plain water
26%
National Family Health Survey - 2

24. Percent of Breastfed Children Given Solid/Mushy Food
Should begin solid/mushy food at 6 mos.
According to WHO recommendations, by the age of 6 months, all children should be given solid or mushy foods in addition to breast milk. The blue bar here represents the period 6-9 months………or that critical period to begin…with the top of the blue bar representing 100% of all children.
1. You can see by the red line here that initiation of solid foods starts late in Bihar
2. Only 16 percent of breastfeeding children age 6-9 months receive solid or mushy food, as recommended………..
3. Even at age months, we found that about one-third (35%) of children were still not receiving any solid foods. [click for arrow]
Source: Table: 7.7, p. 170.
Months
National Family Health Survey - 2

25. Summary of Infant Feeding Practices
Prolonged breastfeeding is quite common
Initiation of breastfeeding is late
Bottle feeding is not common
About half of infants below 4 months are breastfed exclusively, as recommended
Introduction of solid or mushy food is much later than recommended for a majority of children
1. This slide presents a summary of the findings for this sub-section:
- Although prolonged breastfeeding is quite common, initiation is late.
- Bottle feeding is not common.
- A little more than half of infants below 4 months are breastfed exclusively, as recommended
- Introduction of solid and semi-solid foods occurs at a much later age than is recommended for a majority of children.
National Family Health Survey - 2

26. Contents of Presentation
Food Consumption
Nutritional Status of Women and Children
Infant Feeding Practices
Anaemia Prevalence
Next we turn to an examination of anaemia prevalence.
1. Anaemia is characterized by a low level of hemoglobin in the blood. Hemoglobin is necessary for transporting oxygen from the lungs to tissues and other organs.
2. Anaemia typically results from a nutritional deficiency of iron, folate, vitamin B12, or some other nutrients. This type of anaemia is called iron-deficiency anaemia.
3. Note that this was the first time in India that anaemia levels were estimated for the country as a whole, based on a representative sample of women and children.
National Family Health Survey - 2

27. National Family Health Survey - 2
Anaemia
Iron deficiency anaemia is the most widespread form of malnutrition in the world, affecting more than 2 billion people
1. Anaemia is a serious public health issue worldwide, with more than 2 billion people estimated to be affected by it.
2. Anaemia contributes to maternal mortality as well as perinatal mortality. It also increases the risk of preterm delivery and low birth weight infants.
3. Anaemia prevalence information can assist program planners and managers in the development of health interventions designed to prevent iron-deficiency anaemia, such as food fortification or supplementation programs.
National Family Health Survey - 2

28. Method of Testing Anaemia
Used portable, battery-operated HemoCue instrument in the field
Health investigators trained by AIIMS and IIPS
Test requires a single drop of blood from a finger prick
In less than one minute, haemoglobin level indicated on a digital read-out
Results given to women at the time of the test
1. This slide describes the testing method employed in the survey.
2. The instrument used, the HemoCue, looks like this; so far, this instrument has been used in 80 countries to conduct more than 500 million hemoglobin tests, and its validity has been repeatedly confirmed in scientific tests (see accompanying description explaining the HemoCue.)
3. The team conducted centralized training of all health investigators to ensure standardization…... and three medical doctors monitored the work of the health investigators in the field.
4. In addition to giving the respondent the results of the test, with her consent, local health officials were given a list of severely anaemic women and children for follow-up care.
National Family Health Survey - 2

29. Anaemia Among Women in Bihar
In all, 88% of women surveyed were tested. Of these women, 63% were found to have some degree of anaemia
Anaemia levels were substantial for all population groups
Percent
Percent
1. And here are the results. In all, 88% of women in Bihar were tested and almost two thirds of the women (63%) had anaemia, which is a proportion much higher than the national average of 52%. In fact, Bihar ranks among the top seven states with 60 percent or more of women with some degree of anaemia.
2. The breakout of degree of anaemia in Bihar is: 43% of women are mildly anaemic, 19% are moderately anaemic, and 2 % are severely anaemic.
3. Prevalence of anaemia is much higher in Jharkhand (73%) as compared to North Bihar Plain or South Bihar Plain regions (60 to 61%).
4. The proportion of such women is higher for illiterate women (66%) as compared to literate and educated women. Also, the proportions of women with moderate and severe anaemia tend to decrease as standard of living rises.
Source: NFHS-1: Table 7.4. ; All-India Report, page 252, Table 7.7
National Family Health Survey - 2

30. National Family Health Survey - 2
Anaemia in Women
Percent
1. While anaemia levels are substantial for women in every population group, there is little difference between rural women (64 percent) and urban women (60 percent).
2. Prevalence levels are highest for those from households with a low standard of living (69%) as compared to a high standard of living (50%).
Source: Table 7.4, pp
National Family Health Survey - 2

31. Anaemia in Pregnancy (Moderate and Severe Levels)
1. As this chart shows, for levels of moderate and severe anaemia, there are significant differences between pregnant and nonpregnant women who are not breastfeeding. In fact, 28 percent of pregnant women suffer moderate to severe anaemia, as compared to 19 percent of non-pregnant, non-breastfeeding women. This shows that moderate and severe anaemia prevalence among pregnant women continues to be a critical problem in Bihar as a whole.
2. However, pregnant women are considerably less likely than other women to have mild anaemia, probably because a substantial proportion of pregnant women consume iron and folic acid tablets or syrup. Overall pregnant women are considerably less likely to be anaemic (50%) than nonpregnant women (63-67%).
Source: anaemia prevalence, Table 7.4, p. 164, and narrative on p. 166.
Percent
National Family Health Survey - 2

32. Anaemia Among Children Age 6-35 Months
Percent
1. Anaemia among children is a serious concern since it can result in impaired cognitive performance, behavioral and motor development, coordination, language development, and scholastic achievement, as well as increased morbidity from infectious diseases.
2. As the chart shows, four-fifths (81 percent) of children 6-35 months in Bihar have some form of anaemia, including 27 percent who are mildly anaemic, 50 percent who are moderately anaemic, and 4 percent who are severely anaemic.
3. Note that moderate and severe levels of anaemia prevalence among children amounting to 54% are much higher than those found for women (21%).
4. There is very little variation across regions in anaemia prevalence among children: the proportions range from 81% in North and South Bihar to 82% in Jharkhand.
Source: Table 7.11, p. 179 and Figure 7.3.
National Family Health Survey - 2

33. Anaemia Among Children by Mother’s Anaemia Status
Percent
1. This slide shows that there is a positive relationship between the haemoglobin levels of mothers and prevalence of anaemia among children.
However, even among children whose mothers are not anaemic, 78 percent of those children are anaemic, and nearly half (49 percent) of those children are moderately to severely anaemic!
Source: Table 7.11
National Family Health Survey - 2

34. Anaemia Among Children by State
Looking across the states, Bihar has the third highest level of anaemia in children among all states. The top four are: Harayana (84%), Rajasthan (82%), Bihar (81%), and Punjab (80%), all well above the all-India level of 74 percent.
Manipur, Kerala, and Nagaland are the only states where less than half of the children are anaemic.
Table 7.19 in all-India report
Percent
National Family Health Survey - 2

35. Percent of Children With Severe Anaemia by State
In terms of children with severe anaemia levels, Bihar with 4%, is slightly below the all-India average of 5%.
Table: 7.19 in the national report
Percent
National Family Health Survey - 2

36. National Family Health Survey - 2
Summary of Anaemia
Two-thirds of women tested were anaemic
28 percent of pregnant women suffer moderate to severe anaemia, compared to 19 percent of non-pregnant, non-breastfeeding women
Four-fifths of children 6-35 months have some form of anaemia -- the third-highest level among all states
Even when mothers are not anaemic, half of children have moderate or severe anaemia
1. This slide presents a summary of the findings for this sub-section:
- Although prolonged breastfeeding is quite common, initiation is late.
- Bottle feeding is not common.
- A little more than half of infants below 4 months are breastfed exclusively, as recommended
- Introduction of solid and semi-solid foods occurs at a much later age than is recommended for a majority of children.
National Family Health Survey - 2