Improving nutrition in Ladakh:Trends in outcomes, determinants and interventions between 2006 and 2020

Improving nutrition in Ladakh
Trends in outcomes, determinants and interventions
between 2006 and 2019
VERSION: March 15, 2021
This slide deck is an evolving work in progress, with updates being made frequently. If you want to use or
cite this, please email us at IFPRI-POSHAN@cgiar.org to receive the most updated version

Nutrition on India’s policy agenda
• The Prime Minister's Overarching Scheme for Holistic Nutrition or POSHAN Abhiyaan or National Nutrition Mission, is
Government of India's flagship effort to improve maternal and child nutrition outcomes by 2022.
• India launched POSHAN Abhiyaan on 8th March 2018. The contours of the Mission are being updated in 2021.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
2014 (6 mo): New
administration
established);
Nutrition community
develops LAA 2014
2015: NITI Aayog
established; Policy
priorities: Digital
India, Aadhar,
Sanitation Mission;
nutrition still a
“learning agenda”.
Other social welfare
programs reviewed
(e.g., NREGA)
2016: Stated policy
priorities
implemented.
Nutrition mission
inputs received from
multiple groups; July
finance ministry
meeting on nutrition
2017: Final nutrition
strategy unveiled by
NITI Aayog in
September;
acknowledges
underlying issues
(poverty, etc.) but
actions still focused
on ICDS-health
programs
2018: Nutrition
Mission launched in
March – strong ICDS-
Health-Sanitation
link. Poverty/food
insecurity still not
central to agenda
2019: Election year.
Nutrition Mission
strongly visible and
implemented (focus
on BCC, awareness);
poverty alleviation
not part of nutrition
agenda
2021: Mission
POSHAN 2.0
launched in Union
Budget 2021 to
improve nutritional
outcomes.

Data and analysis
• Data sources for trends analysis: National Family Health Survey (NFHS-3 (2006), NFHS-4 (2016) and
NFHS-5 (2019)).
– Child nutrition outcomes: all child data
– Adult nutrition outcomes: man or woman data
– Immediate and underlying determinants: last-child data
– Intervention coverage: last-child data
• Data sources for head count analysis: Census 2011 data to project district-level population of
children under 5 year, women aged 15-49, men aged 15-54 for the year 2019
– Number of pregnant and lactating women at district-level are estimated using HMIS data for the year 2019 and
prevalence from NFHS-5 factsheet
• All the indicators are mapped to the POSHAN Abhiyaan monitoring framework
• Descriptive statistics were estimated, and trend analysis was conducted to examine changes in
outcomes, determinants, and coverage of interventions across the three time periods (2006, 2016
and 2019)
• District level headcount of undernutrition outcomes was computed using undernutrition prevalence
and projected population data for 2019
Note: NFHS-5 data source: Factsheets for 22 states/UTs
Background
Nutrition
outcomes
Determinants
Intervention
coverage

MORTALITY & NUTRITION OUTCOMES

Infant & child mortality rates in Ladakh, per 1,000 live births
(2006, 2016 & 2019)
Source: NFHS-5 state factsheets (2019)
Background
Nutrition
outcomes
Determinants
Intervention
coverage
11.4 20.0 29.5
0
20
40
60
80
100
2006 2016 2019 2006 2016 2019 2006 2016 2019
Neonatal mortality rate Infant mortality rate Under-five mortality rate
Mortality
rate
(per
1000)
Ladakh 2006 Ladakh 2016 Ladakh 2019 India average
*p<0.05, difference between 2006 and 2016 at the state level

Trends in undernutrition outcomes in Ladakh
(2006, 2016 & 2019)
Source: NFHS-3 (2006), NFHS-4 (2016) & NFHS-5 state factsheets (2019)
Undernutrition among children <5y Undernutrition among women (15-49y)
Note: Data on children < 5y who had low birth weight not available in NFHS-5 factsheets (2019)
Background
Nutrition
outcomes
Determinants
Intervention
coverage
NA 30.5 17.5 9.1 20.4 92.5 4.4 93.7 78.1
0
20
40
60
80
100
Low birth weight Stunting Wasting Severe wasting Underweight Anemia Underweight Anemia
(non-pregnant)
Anemia
(pregnant)
%

Inter-district variability in undernutrition outcomes
in Ladakh (2019)
Source: NFHS-5 state & district factsheets (2019)
Undernutrition among children
<5y
Undernutrition among women
(15-49y)
District average 2019
State average 2019
Background
Nutrition
outcomes
Determinants
Intervention
coverage
31 18 9 20 93 4 94 78
0
20
40
60
80
100
Stunting Wasting Severe wasting Underweight Anemia Underweight Anemia
(non pregnant)
Anemia
(pregnant)
%

Trends in overweight/obesity & non-communicable diseases
in Ladakh (2006, 2016 & 2019)
Note: Data on blood pressure and sugar levels not available in NFHS-3 (2006)
Source: NFHS-3 (2006), NFHS-4 (2016) & NFHS-5 state factsheets (2019)
Background
Nutrition
outcomes
Determinants
Intervention
coverage
13 28 38 12 14 4 4
0
20
40
60
80
100
Overweight/ obesity
child
Overweight/ obesity
women
Overweight/ obesity
men
High blood pressure
women
High blood pressure
men
High sugar level
women
High sugar level
men
%

Inter-district variability in overweight/obesity & non-
communicable diseases in Ladakh (2019)
Note: Data on prevalence of overweight among men not available at district level in NFHS-5 (2019). District level information not available in NFHS 3 (2005-06).
Source: NFHS-5 state & district factsheets (2019)
State average 2019
Background
Nutrition
outcomes
Determinants
Intervention
coverage
13 28 38 12 14 4 4
0
20
40
60
80
100
Overweight/
obesity
child
Overweight/
obesity
women
Overweight/
obesity
men
High blood
pressure
women
High blood
pressure
men
High sugar
level
women
High sugar
level
men
%

Stunting among children <5 years in Ladakh (2016 & 2019):
Source: NFHS-4 (2016) & NFHS-5 district & state factsheets (2019)
Note: Stunting prevalence ≥30% is considered to be very high for public health significance. Source: de Onis et al. (2018).
Top 10 districts with highest change in prevalence between 2016 & 2019
District Change (pp)
1 Baramulla -9.8
2 Reasi -9.4
3 Kathua -8.7
4 Kupwara -6.8
5 Ramban -6.8
6 Rajouri -5.9
7 Doda -5.0
8 Udhampur -4.5
9 Ganderbal -3.6
10 Pulwama -2.0
Background
Nutrition
outcomes
Determinants
Intervention
coverage
Leh
Kargil

Number of stunted children <5 years in Ladakh (2019)
Source: IFPRI estimates - The headcount was calculated as the product of the undernutrition prevalence and the total eligible projected population for each
district in 2019. Prevalence estimates were obtained from NFHS 5 (2019) and projected population for 2019 was estimated using Census 2011.
District
Stunted children
(number)
11 Poonch 10,124
12 Kulgam 9,608
13 Kathua 8,363
14 Bandipore 7,080
15 Ramban 6,550
16 Kishtwar 4,923
17 Reasi 4,565
18 Samba 4,392
19 Ganderbal 4,283
20 Shupiyan 4,267
Note: The unit of the numbers in the graph above is thousands
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Stunted children
(number)
1 Anantnag 27,578
2 Srinagar 24,680
3 Kupwara 21,982
4 Jammu 20,718
5 Badgam 19,025
6 Baramulla 17,722
7 Rajouri 14,999
8 Udhampur 14,537
9 Pulwama 10,717
10 Doda 10,713

Wasting among children <5 years in Ladakh (2016 & 2019)
Note: Wasting prevalence ≥15% is considered to be very high for public health significance. Source: de Onis et al. (2018).
Background
Nutrition
outcomes
Determinants
Intervention
coverage
1 Srinagar -9.9
2 Doda -8.0
3 Reasi -4.1
4 Ramban -3.0
5 Poonch -3.0
6 Jammu 2.1
7 Kulgam 2.4
8 Baramulla 3.5
9 Pulwama 4.7
10 Kishtwar 4.9

Number of wasted children <5 years in Ladakh (2019)
Source: IFPRI estimates - The headcount was calculated as the product of the undernutrition prevalence and the total eligible projected
population for each district in 2019. Prevalence estimates were obtained from NFHS 5 (2019) and projected population for 2019 was estimated
using Census 2011.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Wasted children
(number)
11 Shupiyan 6,362
12 Poonch 6,098
13 Ganderbal 5,996
14 Kishtwar 4,081
15 Ramban 3,976
16 Bandipore 3,934
17 Kulgam 3,823
18 Samba 3,657
19 Reasi 3,353
20 Doda 3,112
District
Wasted children
(number)
1 Anantnag 24,350
2 Kupwara 22,158
3 Srinagar 13,911
4 Baramulla 13,902
5 Jammu 13,812
6 Badgam 13,417
7 Rajouri 11,138
8 Kathua 8,631
9 Udhampur 7,717
10 Pulwama 7,320

Severe wasting among children <5 years in Ladakh (2016 &
2019)
Source: NFHS-4 (2015-16) & NFHS-5 district & state factsheets (2019)
Background
Nutrition
outcomes
Determinants
Intervention
coverage
1 Srinagar -10.4
2 Doda -4.9
3 Ramban -3.8
4 Poonch -2.9
5 Reasi -2.0
6 Baramulla 0.1
7 Pulwama 0.8
8 Kulgam 1.4
9 Jammu 1.5
10 Bandipore 2.6

Number of severely wasted children <5 years in Ladakh (2019)
Source: IFPRI estimates - The headcount was calculated as the product of the undernutrition prevalence and the total eligible projected population for each
district in 2019. Prevalence estimates were obtained from NFHS 5 (2019) and projected population for 2019 was estimated using Census 2011.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Severely wasted
children (number)
11 Ganderbal 3,079
12 Pulwama 3,062
13 Kishtwar 2,739
14 Poonch 2,580
15 Doda 1,966
16 Samba 1,757
17 Ramban 1,682
18 Kulgam 1,624
19 Reasi 1,367
20 Bandipore 1,292
District
Severely wasted
children (number)
1 Anantnag 13,691
2 Kupwara 12,977
3 Jammu 7,980
4 Baramulla 6,722
5 Badgam 6,460
6 Rajouri 5,940
7 Srinagar 5,684
8 Kathua 5,025
9 Udhampur 3,741
10 Shupiyan 3,375

Underweight children <5 years in Ladakh (2016 & 2019)
Note: Underweight prevalence ≥30% is considered to be very high for public health significance (used similar cut-off as stunting). Source: de Onis et al. (2018).
Background
Nutrition
outcomes
Determinants
Intervention
coverage
1 Reasi -13.0
2 Srinagar -12.4
3 Doda -8.8
4 Poonch -3.6
5 Kishtwar -3.0
6 Jammu -1.8
7 Baramulla 0.2
8 Ramban 0.8
9 Kathua 3.7
10 Udhampur 3.8

Number of underweight children <5 years in Ladakh (2019)
using Census 2011.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Underweight
children (number)
11 Poonch 7,349
12 Shupiyan 6,498
13 Ramban 5,403
14 Kulgam 5,176
15 Doda 4,980
16 Bandipore 4,720
17 Ganderbal 4,653
18 Kishtwar 3,168
19 Reasi 3,017
20 Samba 2,778
District
Underweight
children (number)
1 Anantnag 27,675
2 Kupwara 22,512
3 Rajouri 16,039
4 Badgam 14,623
5 Jammu 13,505
6 Baramulla 13,215
7 Udhampur 12,432
8 Srinagar 11,816
9 Kathua 9,935
10 Pulwama 9,664

Anemia among children <5 years in Ladakh (2016 & 2019)
Note: : Anemia prevalence ≥40% is considered to be a severe public health problem. Source: WHO (2011).
Background
Nutrition
outcomes
Determinants
Intervention
coverage
Anemia decreased slightly
in one district.
Anemia increased in nine
districts. However, this
increase is relatively lower
compared to other districts
of Ladakh
1 Shupiyan -3.1
2 Poonch 2.8
3 Kupwara 3.9
4 Udhampur 5.6
5 Reasi 6.4
6 Baramulla 8.2
7 Ramban 11.6
8 Pulwama 13.9
9 Badgam 14.0
10 Bandipore 17.1

Number of anemic children <5 years in Ladakh (2019)
using Census 2011.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Anemic children
(number)
11 Kulgam 23,613
12 Kathua 23,088
13 Poonch 19,067
14 Bandipore 18,955
15 Ganderbal 18,675
16 Reasi 16,148
17 Kishtwar 14,231
18 Ramban 14,194
19 Samba 11,110
20 Shupiyan 9,949
District
Anemic children
(number)
1 Anantnag 69,576
2 Kupwara 62,491
3 Badgam 54,203
4 Srinagar 51,730
5 Baramulla 48,307
6 Jammu 47,148
7 Rajouri 33,974
8 Pulwama 28,966
9 Udhampur 24,647
10 Doda 23,749

Underweight women, 15-49 years in Ladakh (2016 & 2019)
Note: Underweight prevalence ≥40% is considered as very high prevalence. Source: WHO (1995)
Background
Nutrition
outcomes
Determinants
Intervention
coverage
1 Udhampur -15.1
2 Samba -12.9
3 Rajouri -12.7
4 Kupwara -10.7
5 Kathua -10.5
6 Jammu -9.9
7 Doda -9.7
8 Reasi -9.2
9 Kishtwar -7.7
10 Poonch -7.5

Underweight women, 15-49 years in Ladakh (2019)
using Census 2011.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Underweight
women (number)
11 Udhampur 6,796
12 Ganderbal 6,748
13 Ramban 6,107
14 Doda 6,084
15 Pulwama 5,134
16 Reasi 3,897
17 Samba 3,826
18 Kishtwar 3,467
19 Kulgam 2,843
20 Shupiyan 1,728
District
Underweight
women (number)
1 Baramulla 32,372
2 Jammu 21,545
3 Srinagar 14,648
4 Anantnag 13,044
5 Bandipore 12,389
6 Kupwara 11,065
7 Kathua 10,384
8 Badgam 9,896
9 Poonch 9,402
10 Rajouri 8,965

Anemia among non-pregnant women, 15-49 years in Ladakh (2016
& 2019)
Source: NFHS-4 (2016) & NFHS-5 district and state factsheets (2019)
Note: Anemia prevalence ≥40% is considered to be a severe public health problem. Source: WHO (2011).
Background
Nutrition
outcomes
Determinants
Intervention
coverage
Anemia decreased in two
districts.
Anemia increased in five
districts. However, this increase
is relatively less compared to
other districts of Ladakh.
1 Srinagar -8.2
2 Udhampur -1.1
3 Badgam 4.7
4 Kupwara 6.2
5 Shupiyan 9.6
6 Kathua 15.2
7 Ramban 15.4
8 Pulwama 15.7
9 Baramulla 17.5
10 Reasi 18.3

Number of non-pregnant anemic women, 15-49 years
in Ladakh (2019)
using Census 2011.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Non-pregnant anemic
women (number)
11 Udhampur 97,353
12 Bandipore 88,511
13 Doda 82,619
14 Poonch 77,839
15 Ganderbal 68,266
16 Samba 67,596
17 Reasi 58,993
18 Kishtwar 58,604
19 Shupiyan 56,606
20 Ramban 49,576
District
Non-pregnant anemic
women (number)
1 Jammu 3,49,848
2 Anantnag 2,40,841
3 Baramulla 2,23,242
4 Srinagar 2,19,726
5 Kupwara 1,64,023
6 Badgam 1,57,911
7 Pulwama 1,32,251
8 Rajouri 1,15,795
9 Kathua 1,08,153
10 Kulgam 1,04,925

Anemia among pregnant women, 15-49 years (2016 & 2019)
Note: : Anemia prevalence ≥40% is considered to be a severe public health problem. Source: WHO (2011).
Background
Nutrition
outcomes
Determinants
Intervention
coverage
1 Kupwara -38.4
2 Shupiyan -15.6
3 Ramban -13.2
4 Pulwama -11.7
5 Udhampur -11.6
6 Kathua -9.7
7 Srinagar -5.7
8 Badgam -4.3
9 Poonch -3.5
10 Rajouri -3.2

Number of pregnant anemic women, 15-49 years
in Ladakh (2019)
using Census 2011.
Background
Nutrition
outcomes
Determinants
Intervention
coverage
District
Pregnant anemic
women (number)
11 Doda 3,871
12 Pulwama 3,573
13 Kathua 3,427
14 Ganderbal 3,288
15 Poonch 3,135
16 Reasi 2,932
17 Kishtwar 2,841
18 Ramban 2,678
19 Samba 2,088
20 Shupiyan 1,669
District
Pregnant anemic
women (number)
1 Srinagar 37,940
2 Jammu 30,289
3 Baramulla 13,105
4 Anantnag 12,408
5 Udhampur 7,306
6 Kupwara 7,145
7 Badgam 7,015
8 Kulgam 6,379
9 Rajouri 6,177
10 Bandipore 3,919

Mixed picture on infant feeding: Women with low BMI decreased rapidly between 2006 and 2016 and continued to decrease steadily between 2016 and
2019. Early initiation of breastfeeding increased gradually between 2006 and 2016 then between 2016 and 2019. Consumed IFA 100+ days increased sharply
between 2006 and 2016 but stagnated between 2016 and 2019. Timely introduction of complementary foods, diarrhea and symptoms of ARI in the last two
weeks decreased between 2006 and 2016 then further between 2016 and 2019. Adequate diet increased between 2006 and 2016 but then decreased
sharply between 2016 and 2019.
Changes in immediate determinants of child undernutrition
in Ladakh (2006, 2016 & 2019)
Source: NFHS-3 (2006), NFHS-4 (2016) & NFHS-5 state factsheet (2019)
Note: Data on continued breastfeeding at 2 years not available in NFHS-5 factsheets (2019); ⁰Indicator comparable between NFHS-3 and NFHS-4 but not with NFHS-5
Background
Nutrition
outcomes
Determinants
Intervention
coverage
0
20
40
60
80
100
2006 2016 2019
%
Women with body mass index <18.5 kg/m2⁰
Consumed IFA 100+ days
Early initiation of breastfeeding
Exclusive breastfeeding
Timely introduction of complementary foods⁰
Continued breastfeeding at 2 years
Adequate diet
Diarrhea in the last two weeks⁰
ARI in the last two weeks⁰

Inter-district variability in immediate determinants
in Ladakh (2019)
State average 2019
Background
Nutrition
outcomes
Determinants
Intervention
coverage
Source: NFHS-5 district & state factsheets (2019)
Note: Data on continued breastfeeding at 2 years not available in NFHS-5 factsheets (2019)
4 14 58 71 24 9 5
0.0
20.0
40.0
60.0
80.0
100.0
Women with body
mass index <18.5
kg/m2
Consumed IFA
100+ days
Early initiation of
breastfeeding
Exclusive
breastfeeding
Timely
introduction of
complementary
foods
Continued
breastfeeding at 2
years
Adequate diet Diarrhea in the
last two weeks
ARI in the last two
weeks
%

Changes in underlying determinants of child undernutrition in
Ladakh (2006, 2016 & 2019)
All underlying determinants improved steadily between 2006 and 2019. Large improvements in HHs with improved sanitation facility and women with
10 or more years of education. Additionally, getting married before the age of 18 reduced drastically from 2006 to 2019. Open defecation and first birth
before the age of 20 decreased between 2006 and 2016.
Source: NFHS-3 (2006), NFHS-4 (2016) & NFHS-5 state factsheets (2019); ⁰Indicator comparable between NFHS-3 and NFHS-4 but not with NFHS-5
Note 1: Data on age at first birth < 20 years, open defecation, safe disposal of feces, and HHs with BPL card not available in NFHS-5 factsheets (2019). Data on HHs with hand washing facility not available in NFHS-3 and NFHS-5 factsheets (2019).
Note 2: Several of these determinants are applicable for maternal undernutrition as well
Background
Nutrition
outcomes
Determinants
Intervention
coverage
0
20
40
60
80
100
2006 2016 2019
%
Women who are literate⁰
Women with ≥10 years education⁰
Girls married before age of 18 years⁰
Age at first birth <20 years
HHs with improved drinking water source⁰
HHs with improved sanitation facility⁰
HHs with hand washing facility
Open defecation
Safe disposal of feces
HHs with BPL card
HHs with electricity⁰

Inter-district variability in underlying determinants in Ladakh
(2019)
District average (2019)
State average (2019)
Background
Nutrition
outcomes
Determinants
Intervention
coverage
Source: NFHS-5 district and state factsheets (2019)
Note 1: Data on age at first birth < 20 years, open defecation, safe disposal of feces, and HHs with BPL card not available in NFHS-5 factsheets (2019). Data on HHs with hand washing facility not available in NFHS-3 and NFHS-5 factsheets (2019).
Note 2: Several of these determinants are applicable for maternal undernutrition as well
77 50 3 89 42 100
0.0
20.0
40.0
60.0
80.0
100.0
Women
who are
literate
Women
with ≥10
years
education
Girls
married
before age
of 18 years
Age at first
birth <20
years
HHs with
improved
drinking
water
source
HHs with
improved
sanitation
facility
HHs with
hand
washing
facility
Open
defecation
Safe
disposal of
feces
HHs with
BPL card
HHs with
electricity
(%)

COVERAGE OF NUTRITION INTERVENTIONS

Interventions across the first 1000 days in Ladakh (2006,
2016 & 2019)
PREGNANCY DELIVERY & POSTNATAL EARLY CHILDHOOD
Note 1 : Information on preconception and pregnancy related indicators including demand for FP satisfied, receipt of at least one ANC visit, received IFA tab/syrup, deworming, weighing, birth preparedness and breastfeeding counselling,
counselling on keeping baby warm, cord care counselling, food supplementation, health and nutrition education and malaria prevention, lactation related indicators including cash transfer (JSY), food supplementation and health and nutrition
education, and early childhood related indicators including pediatric IFA, deworming, food supplementation (6-35m), weighing and counselling on child growth are not available in NFHS-5 factsheets (2019). Information on use of bed nets during
pregnancy not available in NFHS 3 data (2006).
Note 2: Food supplementation during early childhood is for children aged 6-35 months; counselling on child growth during early childhood is conducted after taking weight measurement
Note 3: Refer to district dashboard for the inter-district variability in the coverage of interventions
Source: NFHS-3 (2006), NFHS-4 (2016) & NFHS-5 state factsheets(2019)
⁰Indicator comparable between NFHS-3 and NFHS-4 but not with NFHS-5
Background
Nutrition
outcomes
Determinants
Intervention
coverage
0
20
40
60
80
100
Demand
for
FP
satisfied
Iodized
salt⁰
Any
ANC
visits
≥
4ANC
Received
MCP
card
Received
IFA
tab/syrup
Tetanus
injection
Deworming
Weighing
Birth
preparedness
counselling
Breastfeeding
counselling
Counselling
on
keeping
baby
warm
Cord
care
counselling
Food
supplementation
Health
&
nutrition
education
Malaria
prevention-
use
of
bed
nets
Institutional
birth⁰
Financial
assistance
(JSY)
Skilled
birth
attendant
Postnatal
care
for
mothers
Postnatal
care
for
babies
Food
supplementation
Health
&
nutrition
education
Full
immunization⁰
Vitamin
A⁰
Pediatric
IFA
Deworming
Care
seeking
for
ARI⁰
ORS
during
diarrhea⁰
Zinc
during
diarrhea⁰
Food
supplementation
(6-35
months)
Weighing
Counselling
on
child
growth
(%)
2019 2016 2006

Coverage of nutrition related interventions in Ladakh : district
dashboard (2019)
Background
Nutrition
outcomes
Determinants
Intervention
coverage
Source: NFHS-5 district & state factsheets (2019)
<25% 25-<50% 50-<75% >75% Not Available

0
20
40
60
80
100
≥
4ANC
Received
MCP
card
Tetanus
injection
Institutional
birth⁰
Skilled
birth
attendant
Postnatal
care
for
mothers
Postnatal
care
for
babies⁰
Full
immunization⁰
Vitamin
A⁰
Care
seeking
for
ARI⁰
ORS
during
diarrhea⁰
Zinc
during
diarrhea⁰
%
2019 2016 2006
0
20
40
60
80
100
2006 2016 2019
%
Women with body mass index <18.5 kg/m2⁰
Consumed IFA 100+ days
Early initiation of breastfeeding
Exclusive breastfeeding
Timely introduction of complementary foods⁰
Adequate diet
Diarrhea in the last two weeks⁰
0
20
40
60
80
100
Overweight/
obesity
child
Overweight/
obesity
women
Overweight/
obesity
men
High blood
pressure
women
High blood
pressure
men
High sugar
level
women
High sugar
level
men
(%)
2006 2016 2019
0
20
40
60
80
100
Stunting Wasting Severe
wasting
Underweight
child
Anemia
child
Underweight
women
Anemia
Non pregnant
women
Anemia
Pregnant
women
(%)
2019 2016 2006
0
20
40
60
80
100
2006 2016 2019
%
Women who are literate⁰
Women with ≥10 years
education⁰
Girls married before age of 18
years⁰
HHs with improved drinking
water source⁰
HHs with improved sanitation
facility⁰
HHs with electricity⁰
• Children: Stunting reduced by 7 pp between 2006 and 2016
and by 1 pp between 2016 and 2019.Severe wasting
increased between 2006 and 2016 by 2 pp and then by 3 pp
between 2016 and 2019. Anaemia declined by 5 pp between
2006 and 2016 but increased by 19 pp between 2016 and
2019.
• Women: Underweight declined by 19 pp between 2006 and
2019. Anaemia increased by 15 pp among non-pregnant
women and decreased by 12 pp for pregnant women
between 2006 and 2019.
• Undernutrition in children and women is still a significant
public health concern.
• State has potential to make major strides in child and
maternal nutrition
• Majority of immediate & underlying determinants
improved between 2006 and 2019
• Majority of interventions have coverage of ≥60%
• Looking forward for Ladakh:
• Focus to improve MIYCN coverage to 90%;
• Increase efforts to understand & improve IYCF practices
• Invest in childhood determinants to reduce stunting
and underweight among children
• Assess household poverty and food insecurity (no data
available on these in NFHS)
Trends in nutrition outcomes, determinants and coverage of interventions in Ladakh (2006, 2016 and 2019)
Source: NFHS-3 (2006), NFHS-4 (2016) & NFHS-5 state & district factsheets (2019)
⁰Indicator comparable between NFHS-3 and NFHS-4 but not with NFHS-5
Undernutrition outcomes Overweight/obesity and non communicable diseases
Immediate determinants Key takeaways
Underlying determinants
Interventions across the first 1000 days
PREGNANCY DELIVERY & POSTNATAL EARLY CHILDHOOD

Annex: Methodological notes
• Nutrition outcomes, their immediate and underlying determinants, and nutrition related interventions were identified following the Poshan Abhiyaan
monitoring framework.
• The selected indicators were harmonized across the National Family Health Survey (NFHS) 3 (2005-06) and 4 (2015-16) data and NFHS 5 factsheets (2019).
For those indicators that were not comparable, details were specified in a footnote.
• The method of women sampling across the three NFHS rounds was compared:
• Descriptive statistics were estimated, and trend analysis was conducted to examine changes in outcomes, determinants, and coverage of interventions
across the three time periods. Further, top 10 districts with the highest change in prevalence between 2016 & 2019 were identified. Statistical software Stata
16.0 and R were used to perform the analyses.
• District level headcount of undernutrition outcomes was computed using undernutrition prevalence and projected population data for the year 2019.
o The prevalence P was calculated as children/women with nutritional deficit (q) divided by the eligible sample of children/women (n) in the district (j) and expressed in percentage as: Pj= (qj/nj)
×100
o The headcount was calculated as the product of P and the total eligible population N for each district: Hj= Pj×Nj
• Findings were visualized using spatial maps, bar graphs and line plots. The maps and other graphs were prepared on R and Excel, respectively.
• Cut-off values for public health significance were based on WHO guidelines on all indicators
https://apps.who.int/iris/bitstream/handle/10665/332223/9789241516952-eng.pdf?ua=1 except severe wasting (based on agreement with UNICEFF)
NFHS – 3 (2005-2006) NFHS-4 (2015-2016) NFHS-5 (2019-2020)
• Target sample size in NFHS-3 was fixed
in terms of ever married women age
15-49 years
• All eligible women age 15-49 i.e. all
women age 15-49 who are usual
members of the selected households
or who spent the night before the
survey in the selected households
were eligible to be interviewed in the
survey.
• Information on sampling strategy not
available yet

Annex: Indicator definitions
Mortality and nutrition outcomes
Neonatal mortality rate Neonatal mortality rate per 1000 live births
Infant mortality rate Infant mortality rate per 1000 live births
Under-five mortality rate Under-five mortality rate (U5MR) per 1000 live births
Low birth weight Percentage of live births in the five years preceding the survey with a reported birth weight less than 2.5 kg, based on either a written record or the mother's recall
Stunting among children Percentage of children age 0-59 months who are stunted i.e. height-for-age z score < -2SD
Wasting among children Percentage of children age 0-59 months who are wasted i.e. weight-for-height z score < -2SD
Severe wasting among children Percentage of children age 0-59 months who are wasted i.e. weight-for-height z score < -3SD
Underweight children Percentage of children age 0-59 months who are underweight i.e. weight-for-age z score < -2SD
Anemia among children Percentage of children age 6-59 months who are anemic i.e. (Hb <11.0 g/dl)
Underweight women Percentage of women age 15-49 whose Body Mass Index (BMI) is below normal (BMI <18.5 kg/m2)
Anemia among non-pregnant women Percentage of non-pregnant women age 15-49 who are anemic (<12.0 g/dl)
Anemia among pregnant women Percentage of pregnant women age 15-49 who are anemic (<11.0 g/dl)
Overweight/obesity - children Percentage of children age 0-59 months who are overweight i.e. weight-for-height z score > 2SD
Overweight/obesity - women Percentage of men age 15-54 who are overweight or obese (BMI ≥25.0 kg/m2)
Overweight/obesity - men Percentage of men age 15-54 who are overweight or obese (BMI ≥25.0 kg/m2)
High blood pressure among women^ Percentage of women age 15-49 with elevated blood pressure (Systolic >140 mm Hg or diastolic >90 mm Hg)
High blood pressure among men^ Percentage of men age 15-54 with elevated blood pressure (Systolic >140 mm Hg or diastolic >90 mm Hg)
High sugar level among women^ Percentage of women age 15-49 with elevated blood pressure (Systolic >140 mm Hg or diastolic >90 mm Hg)
High sugar level among men^ Percentage of men age 15-54 with high blood sugar levels (141-160 mg/dl)
^ Indicator not available in NFHS-3; $ Indicator not available in NFHS-5 factsheets; 0 Indicator comparable between NFHS-3 and NFHS-4 but not with NFHS-5
1 Definition per NFHS-3/NFHS-4 ; 2 Definition as per NFHS-5 factsheet

Immediate determinants
Women with body mass index <18.5
kg/m2 0
1Percentage of women age 15-49 with a youngest child < 5 years who have BMI below normal (BMI <18.5 kg/m2) ; 2Percentage of women age 15-49 whose BMI is
below normal (BMI <18.5 kg/m2)
Consumed IFA 100+ days Percentage of mothers age 15-49 who consumed iron folic acid for 100 days or more during the last pregnancy in last five years preceding the survey
Early initiation of breastfeeding Percentage of children under age 3 years breastfed within one hour of birth for the last child born in the 3 years before the survey
Exclusive breastfeeding Percentage of youngest children under age 6 months living with mother who were exclusively breastfed
Timely introduction of
complementary foods0
1Percentage of youngest children age 6-8 months living with mother who received solid or semi-solid food; 2Percentage of youngest children age 6-8 months living
with mother who received solid or semi-solid food and breastmilk
Continued breastfeeding at 2 years$ Percentage of youngest children 20-23 months living with mother who are fed breastmilk
Adequate diet Percentage of youngest children age 6-23 months living with mother who received an adequate diet
Diarrhea in the last two weeks0 1Percentage of youngest children under age five who had diarrhoea in the two weeks preceding the survey; 2Percentage of children under age 5 who had diarrhoea
in the 2 weeks preceding the survey
ARI in the last two weeks0 1Percentage of youngest children under age five who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey; 2Percentage of
children under age five who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey

Underlying determinants
Women who are literate0 1Percentage of women age 15-49 with a birth in five years preceding the survey who are literate i.e. those who completed standard 6 or higher and can read a
whole sentence; 2Percentage of women age 15-49 who are literate i.e. those who completed standard 9 or higher and can read a whole sentence or part of a
sentence.
Women with ≥10 years education0 1Percentage of women age 15-49 with a birth in five years preceding the survey with 10 or more years of schooling; 2Percentage of women age 15-49 with 10 or
more years of schooling
Girls married before age of 18 years0 1Percentage of women age 20-24 years with a birth in five years preceding the survey who were married before age 18 years; 2Percentage of women age 20-24
years who were married before age 18 years
Age at first birth <20 years$ Percentage of currently married women age 15-49 who had their first birth before age 20 years and in the five years preceding the survey
HHs with improved drinking water
source0
1Percentage of youngest children under age 5 living in household that use an improved source of drinking water; 2Population living in households that use an
improved sanitation facility
HHs with improved sanitation facility0 1Percentage of youngest children under age 5 living in household that uses improved toilet facility; 2Population living in households that use an improved sanitation
facility
HHs with hand washing facility^$ Percentage of youngest children under age 5 living in household that had soap and water for washing hands
Open defecation$ Percentage of youngest children under age 5 living in household that has no toilet facility/defecates in open
Safe disposal of feces$ Percentage of youngest children living with mother whose stools were disposed of safely
HHs with BPL card$ Percentage of youngest children under age 5 living in households with BPL card
HHs with electricity0 1Percentage of youngest children under age 5 living in household that has electricity; 2Population living in households with electricity

Interventions
Demand for FP satisfied$ Percentage of currently married women age 15-49 with demand for family planning satisfied by modern methods
Iodized salt0 1Percentage of women age 15-49 living in HHs that use iodized salt; 2Percentage of households using iodized salt
Any ANC visits$ Percentage of women age 15-49 with a live birth in the five years who received at least one ANC for the last birth
≥ 4ANC Percentage of mothers age 15-49 who had at least 4 antenatal care visits for last birth in the 5 years before the survey
Received MCP card Percentage of mothers who registered last pregnancy in the 5 years preceding the survey for which she received a Mother and Child Protection (MCP) card
Received IFA tab/syrup$ Percentage of women who received IFA (given or purchased) tablets during the pregnancy for their most recent live birth in the 5 years preceding the survey
Tetanus injection Percentage of women whose last birth was protected against neonatal tetanus (for last birth in the five years preceding the survey )
Deworming- pregnancy$ Percentage of women who took an intestinal parasite drug during the pregnancy for their most recent live birth in the 5 years preceding the survey
Weighing- pregnancy$ Percentage of women age 15-49 with a live birth in the five years preceding the survey who were weighed during ANC for the last birth
Birth preparedness counselling$ Percentage of women who had at least one contact with a health worker in the three months preceding the survey and were counselled on birth preparedness;
calculated among women age 15-49 who gave birth in the five years preceding the survey
Breastfeeding counselling$ Percentage of women who met with a community health worker in the last three months of pregnancy and received advice on breastfeeding (for the last
pregnancy in the five years preceding the survey)
Counselling on keeping baby warm$ Percentage of women who met with a community health worker in the last three months of pregnancy and received advice on keeping the baby warm for their
most recent live birth in the five years preceding the survey
Cord care counselling^$ Percentage of women who met with a community health worker in the last three months of pregnancy and received advice on cord care for their most recent live
birth in the five years preceding the survey
Food supplementation - pregnancy$ Percentage of youngest children under age 5 whose mother received supplementary food from AWC during pregnancy
Health & nutrition education –
pregnancy$
Percentage of mothers who received health and nutrition education from an Anganwadi Centre (AWC) during last pregnancy in the five years preceding the survey
Malaria prevention- use of bed
nets^$
Percentage of women who used mosquito net during the pregnancy for their most recent live birth in the 5 years preceding the survey

Interventions
Institutional birth0 1Percentage of women age 15-49 who gave birth in health/institutional facility for their most recent live birth in the 5 years preceding the survey;
2Percentage of live births to women age 15-49 in the five years preceding the survey that took place in a health/institutional facility
Financial assistance (JSY)$
Percentage of women who received financial assistance under JSY for their most recent live birth that took place in institutional facility in the 5 years
preceding the survey
Skilled birth attendant0 1Percentage of women whose last delivery was attended by a skilled health personnel for their most recent live birth in the 5 years preceding the survey;
2Percentage of births attended by skilled health personnel for births in the 5 years before the survey
Postnatal care for mothers Percentage of mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health personnel within 2 days of delivery for their most
recent live birth in the five years preceding the survey
Postnatal care for babies Percentage of children who received postnatal care from a doctor /nurse /LHV /ANM /midwife /other health personnel within 2 days of delivery for last
birth in the 5 years before the survey
Food supplementation – postnatal$
Percentage of youngest children under age 5 whose mother received supplementary food from AWC while breastfeeding
Health & nutrition education – postnatal$
Percentage of youngest children under age 5 whose mother received health check-ups from AWC while breastfeeding
Full immunization0 1Percentage of youngest living children age 12-23 months fully vaccinated based on information from either vaccination card or mother's recall;
2Percentage of children age 12-23 months fully vaccinated based on information from either vaccination card or mother's recall
Vitamin A – early childhood0 1Percentage of youngest children age 6-59 months who received Vitamin A supplementation in the last 6 months preceding the survey; 2 Percentage of
children age 9-35 months who received a vitamin A dose in the last 6 months
Pediatric IFA$
Percentage of youngest children age 6-59 months who received iron supplements in the past 7 days preceding the survey
Deworming – early childhood$
Percentage of youngest children age 6-59 months who received deworming tablets in the last 6 months preceding the survey
Care seeking for ARI0 1Percentage of youngest children under age 5 years with fever or symptoms of ARI in the 2 weeks preceding the survey taken to a health facility or health
provider; 2Percentage of children under age 5 years with fever or symptoms of ARI in the 2 weeks preceding the survey taken to a health facility or health
provider
ORS during diarrhea0 1Percentage of youngest children under age 5 years with diarrhoea in the 2 weeks preceding the survey who received oral rehydration salts (ORS);
2Percentage of children under age 5 years with diarrhoea in the 2 weeks preceding the survey who ORS
Zinc during diarrhea0 1Percentage of youngest children under age 5 years with diarrhoea in the 2 weeks preceding the survey who received zinc; 2Percentage of children under
age 5 years with diarrhoea in the 2 weeks preceding the survey who received zinc
Food supplementation (children 6-35 months) $
Percentage of youngest children age 6-35 months who received food supplements from AWC in the 12 months preceding the survey
Weighing – early childhood$
Percentage of youngest children under age 5 who were weighed at AWC in the 12 months preceding the survey
Counselling on child growth$
Percentage of youngest children under age 5 whose mother received counselling from an AWC after child was weighed in the 12 months preceding the
survey

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