Reduce by 40% the number of

under-five stunted children

Adelheid Onyango

Technical Officer, Growth Assessment and Surveillance Unit

Department of Nutrition for Health and Development

Informal Consultation with Member States and UN Agencies on

A Proposed Set of Indicators for the Global Monitoring Framework for

Maternal, Infant and Young Child Nutrition

WHO/HQ, Geneva, 30 September – 1 October 2013

Outline

• Background for target – Definition – Rationale

• Logical framework linking the indicators • Proposed outcome indicators

– Strengths – Limitations – Data availability

• Proposed process indicators – Strengths – Limitations – Data availability

Background

• Stunting defined as length/height-for-age below -2 SD of the WHO standard median

• Results from cumulative deficits in linear growth caused by factors including inadequate feeding and/or repeated or chronic infections

• The most significant deficits are accumulated in the first 1000 days, from gestation to age 2 y

• After this age, stunting is largely irreversible

• The long term consequences of stunted growth include chronic diseases and economic losses

Agriculture and Food Systems

• Food production and processing

•Availability of micronutrient-rich foods

• Food safety and quality

Inadequate practices • Infrequent feeding • Inadequate feeding

during and after illness • Thin food consistency • Feeding insufficient

quantities • Non-responsive feeding

Health and Healthcare • Access to healthcare • Qualified healthcare

providers • Availability of supplies

•Infrastructure •Health care systems and

policies

Education • Access to quality education

• Qualified teachers • Qualified health educators • Infrastructure (schools and

training institutions)

Food and water safety • Contaminated food and

water • Poor hygiene practices • Unsafe storage and preparation of foods

Concurrent problems & short-term consequences Long-term consequences

Poor quality foods • Poor micronutrient

quality • Low dietary diversity and intake of animal-

source foods • Anti-nutrient content • Low energy content of

complementary foods

Water, Sanitation and Environment

• Water and sanitation infrastructure and services

• Population density •Climate change •Urbanization

• Natural and manmade disasters

Political economy • Food prices and trade

policy • Marketing regulations

• Political stability • Poverty, income and wealth

• Financial services • Employment and

livelihoods

Community and societal factors

Inadequate Complementary Feeding

Stunted Growth and Development

Health ↑Mortality

↑Morbidities

Developmental ↓Cognitive, motor,

and language development

Economic ↑Health

expenditures ↑Opportunity costs for care of sick child

Economic ↓ Work capacity

↓ Work productivity

Developmental ↓School

performance ↓ Learning capacity

Unachieved potential

Health ↓Adult stature ↑Obesity and associated co-

morbidities ↓ Reproductive

health

Infection

Clinical and subclinical infection

• Enteric infection: Diarrhoeal disease,

environmental enteropathy, helminths • Respiratory infections

• Malaria • Reduced appetite due

to infection • Inflammation

Household and family factors

Maternal factors • Poor nutrition during

pre-conception, pregnancy and lactation • Short maternal stature

• Infection • Adolescent pregnancy

• Mental health •IUGR and preterm birth • Short birth spacing • Hypertension

Inadequate practices • Delayed initiation • Non-exclusive breastfeeding

• Early cessation of breastfeeding

Context

Causes

Consequences

Society and Culture • Beliefs and norms

• Social support networks • Child caregivers (parental

and non-parental) • Women’s status

Home environment • Inadequate child

stimulation and activity • Poor care practices •Inadequate sanitation

and water supply • Food insecurity

• Inappropriate intra-household food

allocation • Low caregiver education

Breastfeeding

Actions to prevent stunting

• Improved maternal nutrition and health during pregnancy

• Appropriate infant and young child feeding with supplementation as needed

• Prevention (WASH, ITN use, immunization) and effective treatment of infections

Global trends – 1990 to 2012

Primary outcome indicator

Prevalence of low height-for-age in children <5

years of age defined as <-2 standard deviations

of the WHO Child Growth Standards median

Data availability

• Most nutrition surveys, e.g., MICS, DHS, SMART

and other national/sub-national surveys

Challenges

• Quality of measurements in routine data

• Multiple causes vs limited no. of indicators for the

framework

Agriculture and Food Systems • Food production and

processing •Availability of micronutrient-

rich foods • Food safety and quality

Inadequate practices • Infrequent feeding • Inadequate feeding

during and after illness • Thin food consistency • Feeding insufficient

quantities • Non-responsive feeding

Health and Healthcare • Access to healthcare • Qualified healthcare

providers • Availability of supplies

•Infrastructure •Health care systems and

policies

Education • Access to quality education

• Qualified teachers • Qualified health educators • Infrastructure (schools and

training institutions)

Food and water safety • Contaminated food and

water • Poor hygiene practices • Unsafe storage and preparation of foods

Concurrent problems & short-term consequences Long-term consequences

Poor quality foods • Poor micronutrient

quality • Low dietary diversity and intake of animal-

source foods • Anti-nutrient content • Low energy content of

complementary foods

Water, Sanitation and Environment

• Water and sanitation infrastructure and services

• Population density •Climate change •Urbanization

• Natural and manmade disasters

Political economy • Food prices and trade policy

• Marketing regulations • Political stability

• Poverty, income and wealth • Financial services

• Employment and livelihoods

Community and societal factors

Inadequate Complementary Feeding

Stunted Growth and Development

Health ↑Mortality

↑Morbidities

Developmental ↓Cognitive, motor,

and language development

Economic ↑Health

expenditures ↑Opportunity costs for care of sick child

Economic ↓ Work capacity

↓ Work productivity

Developmental ↓School

performance ↓ Learning capacity

Unachieved potential

Health ↓Adult stature ↑Obesity and associated co-

morbidities ↓ Reproductive

health

Infection

Clinical and subclinical infection

• Enteric infection: Diarrhoeal disease,

environmental enteropathy, helminths • Respiratory infections

• Malaria • Reduced appetite due to

infection • Inflammation

Household and family factors

Maternal factors • Poor nutrition during

pre-conception, pregnancy and lactation • Short maternal stature

• Infection • Adolescent pregnancy

• Mental health •IUGR and preterm birth • Short birth spacing • Hypertension

Inadequate practices • Delayed initiation • Non-exclusive breastfeeding

• Early cessation of breastfeeding

Context

Causes

Consequences

Society and Culture • Beliefs and norms

• Social support networks • Child caregivers (parental

and non-parental) • Women’s status

Home environment • Inadequate child

stimulation and activity • Poor care practices •Inadequate sanitation

and water supply • Food insecurity

• Inappropriate intra-household food allocation • Low caregiver education

Breastfeeding

PO1

IO1: malaria IO2: Diarrhea

PR1: Adequacy PR8: Diversity

PR2: Water PR3: Sanitation

PR4: ITN; PR5: ORS PR9: Immunization

PR6: dietary energy PR10: HH exp on food

Intermediate outcome indicators

Prevalence of malaria • In malaria endemic areas, elsewhere not relevant

• Data from WHO Global Health Observatory

Incidence of diarrhea in under-fives • Associated also with wasting

• Weak cross-sectional association with stunting

Median urinary iodine concentration (μg/L) in children aged 6-12 years • Proxy for HH consumption of iodized salt

• Link with growth questioned

• Different age group from the target population

Process indicators – I

Complementary feeding

• % 6-23 month-olds receiving a minimum acceptable diet

• Mean dietary diversity score (minimum diversity for 6-23 month-olds)

Data availability

• From DHS and MICS (UNICEF ChildInfo database)

• For adults HH food consumption surveys (FAO statistics)

Process indicators – II Household and family factors

• % population using an improved water source

• % population using improved sanitation facilities

• % households having access to iodized salt

• % population below minimum dietary energy consumption

• Average household expenditure on food of the bottom three deciles

Data availability

• WHO Global Health Observatory (World Health Statistics)

• MICS (UNICEF)

• FAO HH Food consumption surveys

Process indicators – III

Community and societal factors: health and healthcare

• Children sleeping under insecticide-treated nets

• % under fives with diarrhea receiving ORS

• Immunization coverage levels

Data availability

• Global Health Observatory (World Malaria Report)

Process indicators – IV

Challenges

• Data from varied sources and sectors, may not

always be accessible

• Sampling frames for the various surveys may not overlap to allow for attribution

• Survey data from non-overlapping periods may

limit plausibility of associations between

processes and outcomes

• Within-country disparities not evident from national

statistics