Nutrition Surveillance: An effective tool in Nutrition Policy

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Nutrition Surveillance An effective tool in
Nutrition Policy

• Chantell Witten
• Country Director
• 2 April 2007

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Background

• Bangladesh has one of the highest malnutrition
  rates in the world
• Relationship between expenditure and malnutrition
  in Bangladesh is not as strong as in other
  developing countries
• GOB and DPs invested large sums of money to
  tackle malnutrition but the progress needs to be
  accelerated
• Among households in wealthiest quintile (5th) the
  level of malnutrition is still high
  (IFPRI/DFID-B, 2004 HKI, 2006)
• One of the key gaps lack of in-depth data and
  analysis for formulating nutrition
  policies/program (IFPRI/DFID-B, 2004)
• Surveillance offers more than survey data for
  appropriate policy and action (intervention)

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Modified from WB,2004
Income Poverty
Low Food Intake
Frequent Infections
Hard physical labour
Frequent pregnancies
Large families
Malnutrition
Indirect loss in productivity from poor cognitive
development and schooling
Direct loss in productivity form poor physical
status
Indirect loss in productivity from poor cognitive
development and schooling
Loss in resources from increased health care
costs of ill-health
Loss in resources from increased health care
costs of ill-health
Direct loss in productivity from poor physical
status
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Types of malnutrition
45,7
11,1
39,2
Multiple micronutrient deficiencies
Chronic energy deficiency
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Malnutrition in Bangladesh

• Addressing malnutrition is core to the
  development agenda
• Malnutrition in Bangladesh is a problem of
• food insecurity
• low diet diversity
• poor health and water sanitation status
• Poverty is underlying each of these
• High levels of malnutrition is still evident even
  amongst the wealthiest 20

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Role of nutrition and health surveillance

• Track progress towards national and international
  targets, including health, nutrition and poverty.
• Facilitate to design, monitor and evaluate
  policies and programs to improve health and
  nutrition.
• Assess coverage and impact of programs among
  certain population groups and/or the general
  population.
• Formulate advocacy material to obtain support for
  development efforts.
• Assess the scale of malnutrition and examine
  determinants of malnutrition.

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Nutritional Surveillance Project

• Nationally and Divisionally representative sample
• 16-year data set on the health and nutritional
  status of women and children in Bangladesh
• Richest source of urban slum data in the world
• Data was collected every 2 months to capture
  seasonal trends, a year starts with the
  February-March round ending Dec-January
• Was in collaboration with IPHN (under the MOHFW)
  and local NGOs
• High-quality evidence based outputs

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Scope of indicators collected

• Health and nutrition data of under-fives and
  mothers
• SES and demographic data of the household
• Health care utilization
• Crisis impact and coping
• Agricultural practices
• NNP participation
• Adolescents basic information
• Tobacco survey
• Village level information (prices, distances to
  certain institutions)

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Rajshahi
Sylhet
Dhaka
Map of NSP data collection areas
Chittagong
Khulna
Barisal
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Sampling of the NSP

• Sampling scheme is nationally and divisionally
  representative since 1998 (rural sample).
• Rural NSP (38 thana)
• Each division 4 thana x6 24 thana, 9000 HH
• CHT 4 thana, 1500 HH
• NNP BINP 5 thana x2 10 thana, 3000 HH
• Urban NSP (6 divisional cities)
• Urban slums only
• Sample size proportionate to city size overall
  1500 HH
• Overall sample size 13,500 (rural) 1,500
  (urban)
• ? 15,000 HH every 2 months

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Trends of underweight among rural Bangladeshi
children, from 1990 to 2005
(n 909,178)
WHO threshold for 'very high prevalence
WHO threshold for 'high prevalence
Even well above very high cut off
Moderate (weight-for-age Z-score lt-2SD to
3SD), Severe (weight-for-age Z-score lt-3SD)
Error bars represent 95 confidence intervals
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Trends of stunting among rural Bangladeshi
children, from 1990 to 2005
(n 914,918)
WHO threshold for 'very high prevalence
WHO threshold for 'high prevalence
Moderate (height-for-age Z-score lt-2SD to
3SD), Severe (height-for-age Z-score lt-3SD)
Error bars represent 95 confidence intervals
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Reduction in prevalence of underweight by
expenditure quintiles, 1998 to 2005
(n 61,245)
(n 62,956)
Larger Decline in wealthiest group, still very
high prevalence
WHO threshold for 'very high prevalence
Error bars represent confidence intervals
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Child growth Stunting and its relation to SES

• Stunting
• Short stature for the childs age (height-for-age
  indicator)
• 39 children aged 0-59 months are stunted
• 45 children aged 0-59 months are underwt
• Very strong inverse relationship with SES
• As the area of the house or the level of maternal
• education increase, child stunting decreases
• dramatically.

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Average child height-for-age Z-score (6-59m) by
mothers number of years of formal education
(1990-2000, n547 327)
MW Bloem et al. 2004. Trends in health and
nutrition indicators in the urban slums of three
cities in Bangladesh, compared to its rural
areas. FAO Food and Nutrition Paper No. 83, FAO,
Rome.
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Prevalence of child stunting in MHH and FHH by
expenditure quintile in rural Bangladesh
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Child anemia prevalence in rural Bangladesh in
2001 and 2004
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Prevalence of night blindness among children
(12-59 mo) who had not received VAC by home
garden and poultry ownership
(Kiess et al., submitted for publication)
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(No Transcript)
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Child underweight and the weekly per capita
expenditure on rice
Torlesse et al. 2003, J Nutr 1331320-1325
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The Nutrition Sufficiency Ratio (NSR)

• To assess whether the amount of money spent on
  food was sufficient to purchase foods that would
  provide an optimal diet according to 100 of RDA
  for key nutrients
• NSR gt 1 HH spends enough money on food to
  be able to purchase an optimal diet
• NSR lt 1 HH spends insufficient money on
  food
• to be able to purchase an optimal diet

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Prevalence of stunting for different levels of
the Nutrition Sufficiency Ratio (n73,933)
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Proportion of total expenditure that households
spent on foods and on animal foods (n62,920)
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Treatment seeking behavior for child sickness by
expenditure quintiles
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Micronutrient supplementation coverage among
mothers in rural and urban poor areas of
Bangladesh in 2004
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The WORLD BANK MDG REPORT, 2005

• . . . the importance of systematically
  monitoring MD outcomes at disaggregated levels
  and evaluating the impact of public programs
  cannot be overemphasized. There is a paucity of
  reliable, time-series data on most MD indicators
  at the district and sub-district levels.

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• THANK YOU