Module 5: Nutritional assessment in policy and programmatic application By Tina G. Sanghvi, PhD...

Module 5: Nutritional assessment in policy and programmatic application

By

Tina G. Sanghvi, PhD Senior Country Director Alive & Thrive, FHI360Training on Assessment of Nutritional Status 18-22 December 2011

Date : 22 December 2011, Venue: FPMU Meeting Room

The Training is organized by the National National Food Policy Capacity Strengthening Programme (NFPCSP) . The NFPCSP is jointly implemented by the Food Planning and Monitoring Unit (FPMU), Ministry of Food and Disaster Management and Food and Agriculture

Organization of the United Nations (FAO) with the financial support of the EU and USAID.

Acknowledgements

• M. Ruel, IFPRI. Nutrition and economic growth A&T Partners’ Meeting Hanoi, September 2011

• Lalita Bhattacharjee, FSNSP Dissemination Workshop. December 13 December 13, 2011.

• Mahbub Hossain, BRAC. FSNSP Dissemination Workshop. December 13, 2011

• John B. Mason. Keynote paper: Measuring hunger and malnutrition.FAO Symposium 2002

• IFPRI. Alive & Thrive Baseline Survey 2011.• Haider, Sanghvi et al. Alive & Thrive Formative Research on

IYCF. 2009.

Module 5: Program and Policy Application, Tina Sanghvi PhD

Session Overview• Uses of data for policy & programs

– Examples

• Why dietary adequacy does not always equal nutritional status– Examples


Indicators – Country Investment Plan


Key Indicators Baseline (‘07-’10) Final ‘15-’16)

Overall goal:% People undernourished 27 17.5% Child stunting 43 25% Child underweight 41 33Outcome/impact:Food availability (food supplies) (rice supply & share) Food access (income) - Poverty rate < 2022 kcals/day 40 24 - Poverty rate < 1805 kcals/day 19.5 14Food utilization - Minimum acceptable complementary feeding (quantity & quality of CF 6-23 m)

42 56

Uses of data for policy & programs

• How food & nutrition assessments are used:– Define trends to trigger action– Identify causes to design interventions– Monitor & evaluate effects of programs & policies

• Choice of indicators & interpretation are keyExample: In Bangladesh, food and poverty trends have

improved. Fertility & mortality rates have declined but malnutrition is stagnant. This is triggering actions to find out the causes, evaluate past programs and strengthen nutrition interventions, e.g. CIP, NFP, POA, National Nutrition Service to evaluate their future effects


METHODS OF ASSESSING FOOD SECURITY& NUTRITION & THEIR USE

Method UseTrends analysis Research into

causesEvaluation

(1 ) FAO: DES/CVdietary energy supply

Main use: global and regional level; always under-estimates

Not very useful except for broad inter-country trends

Not very useful

(coefficient of variation)

(2) Household income and expenditure survey

Useful: national and subnational level

Can be useful Useful

(3) Food consumption/ Useful: now available at the national level, thus very useful, captures intra-HH food distrib.

Main use Main use

individual intake (24-hour)

(4) Anthropometry (mother, child weight & height)

Useful at all levels, but for physical malnutrition and not food security

Useful for physical malnutrition not food security

Useful but should also have food security indicators

(5) Qualitative method (food habits)

Useful: national and subnational level

Useful Useful

Questions that can be addressed by different methods

Method UseTrends analysis Causal analysis Evaluation

(1 ) FAO: DES/CVdietary energy supply

Is the supply of food in terms of calories/ energy improving to meet needs, if equitably distributed?

Is the cause of food insecurity & undernutrition due to overall food supply?

Are food supply policies/programs working? Impact of climate change/ disasters on supplies?

(coefficient of variation)

(2) Household income and expenditure survey

Are no. of food secure HH (in energy and nutrients) improving?

Is the cause of problems due to low expenditures on food?

Are programs working to reach the poor?

(3) Food consumption/ Are mothers and young children consuming more adequate diets?

Is the problem food availability/access or dietary habits?

Are programs for women and young children working?

individual intake (24-hr)

(4) Anthropometry (mother/child wt, ht)

Is nutritional status improving?

No Does the program improve nutrition of mothers & children?

(5) Qualitative method (food habits, frequency)

Are food habits improving?

Are habits a barrier? Does the program improve food habits?

How we present and interpret data makes a difference: examples


Trends in food intake (gms/capita/day)

All Urban Rural

1991-92 886 938 8781995-96 914 931 9112005 949 952 9462010 1000 985 1005


•Intakes improving faster in rural areas,•Averages hide disparities among economic groups

Food available in grams per head per day

1991-92 1995-96 2005 2010800

850

900

950

1000

1050

AllUrbanRural


Diversity:-National supplies-Household level

- Child’s diet-Women’s diet


Trends in food content adequacy (gms/capita/day)

Food Recom. 2005 2010 TrendRice 390 440 416Wheat 100 12 26Vegetables 225 220 236Pulses 30 14 14Oil 20 16 21Fish 45 42 49Meat/eggs 34 20 25


Content of food basket: improving diversity

2005 20100

50

100

150

200

250

300

350

400

450

500

Rice

Wheat

Vegetables

Pulses

Oil

Fish

Meat/eggs


Content of food basket: gaps in diversity

0

50

100

150

200

250

300

350

400

450

500

Recom.

2005

2010


Dietary intake assessment is key• RAP –low cost, primary method for collecting dietary data

(locally available /commonly consumed foods, dietary habits, behaviour)

• Household surveys – provide data on foods consumed by HH not individuals

• Point to which foods are major contributors to nutrients of particular concern ( identify vulnerability/at risk of dietary deficiency - e.g lack of animal foods; no fresh vegetables/fruits, lack of DGLV/YOV–lack of vit. C & A in diet)

• Food record and 24 hr recall methods of choice for estimating mean intakes; quantitative dietary intake methods to obtain individual nutrient intakes

• Take measurements for each individual on at least 2 non-consecutive days to obtain intra-individual variation


Why improving food security does not necessarily remove undernutrition


Ruel; A&T Partners' Meeting, Hanoi 9/27/2011

Vietnam Bangladesh Ethiopia0

5

10

15

20

25

30

35

40

45

50

55

13.88

35.38

39.28

19.18

46.3944.52

22.99

47.32 47.07

23.14

53.29

49.88

A&T Baseline: Stunting is High Even in Food Secure Households

Bivariate

Food secureMildly food insecureModerate food insecureSeverely food insecure

+ p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001

PERC

ENT

STU

NTE

D


Factors that determine nutritional status


Adequate Complementary Feeding

Lowest Second Middle Fourth Highest 6-8m 9-11m 12-17m18-23m0

10

20

30

40

50

60

70

80

90

100

38 3847 44 48

16

3648

58

By Wealth Quintiles By Age Groups

BDHS 2007

Quality of Children’s Diets (BDHS, 2007)

0 0 210

2434

48

6471 75

0102030405060708090

100

Age <2 m 2-3 m 4-5 m 6-7m 8-9m 10-11m

12-15m

16-19m

20-23m

24-35m

Meat, Fish, Poultry and Eggs Consumed (< 24 h)

Why is nutrition not improving?• Knowledge: do people know what foods they should

consume by age, sex, occupation, physiological status? • Do families have the resources/motivation to convert

knowledge to practice • If food intakes (energy and nutrients) are adequate,

could there be intervening factors e.g. illness• Pre-disposing factors: maternal undernutrition

seasonal food/income shortages, migration, illness outbreaks, hygiene/sanitation, emergencies

• Importance of under 2’s


Illustration of association between dietary adequacy and anthropometry

• 100• 80• 20• Total sample

• 70• 70• 0• % > -2SDs

• 30• 10• 20• % <-2SDs

• Total under or adequate nutrition

• % with adequate diet

• % with inadequate diet

• Prevalence of under nutrition

Source : Mason, 2002 in “Measurement and Assessment of Food Deprivation and Undernutrition”, FAO

Note: 10% have adequate diets but are still undernourished due to other causes

New focus on under 2 yr age group

• Most rapid decline in nutritional status• Damage is largely not reversible• Affects child growth + adult chronic diseases• Affects brain development/learning as well as

physical development• All national nutrition indicators focus on young

children, to improve MDG 1 have to prevent under 2 decline in nutrition


Goal: To reduce undernutrition, improve IYCF

-2.5

-2

-1.5

-1

-0.5

0

0.5

1 3 5 7 9 11 13 15 17 19 21 23 25

Age (mo)

Len

gth

-fo

r-ag

e Z

-sco

re

Boys WHO Girls WHO

Boys NCHS Girls NCHS

Maximum decline at 3 to 15 months – period of IYCF

EBF-------

Complementary Feeding---------------------------

Growth of girls/ boys NCHS/WHO standards

Growth data: Kuntal K. Saha et al, Food Nutr Bull. 2009; 30: 137-44ICDDRB


CF Provides Adequate Energy & Nutrients

0-2 3-6 7-8 9-11 12-230

100

200

300

400

500

600

700

800

900

1000

Energy Required & Amount From Breastmilk & CF

Compl. FoodBreastmilk

Age in months

Ca

lori

es

pe

r d

ay

200 300

550

½ Bati2 timesDaily +

½ Bati3 timesDaily +

1 Bati3 timesDaily+

Bati = 250 ml

•At least 4 types•Hygienically prepared

Exclusive BF

BF + CF

Recommended diet:


Indicators – Country Investment Plan


Key Indicators Baseline (‘07-’10) Final ‘15-’16)

Overall goal:% People undernourished 27 17.5% Child stunting 43 25% Child underweight 41 33Outcome/impact:Food availability (food supplies) (rice supply & share) Food access (income) - Poverty rate < 2022 kcals/day 40 24 - Poverty rate < 1805 kcals/day 19.5 14Food utilization - Minimum acceptable complementary feeding (quantity & quality of CF 6-23 m)

42 56

Minimum acceptable diet for under 2’s

• 3 conditions must be met:

– Breastfeeding– Meal frequency as per age (2 to 3 times plus snacks)– At least 4 different categories of food

Analysis should be used to focus BCC messages, how to deal with HH food availability, mothers’ time constraints etc.


Gaps in feeding

Initiation

EBF < 6m

CF 6-8

CF 9-11

CF 12-17

CF 18-24

Stunting

Mat. A

n.

Child An.

0

10

20

30

40

50

60

70

80

90

100

43 43

16

36

48

58

4347

68

Complementary Feeding

BDHS 2007, WHO (HKI 2006)

Median EBF 1.8 m

Breastfeeding


Main messages• What is needed to ensure food security &

nutrition results:– Food availability - Food access - Food utilization– Behavior change communications to promote

specific dietary & health habits• Disaggregated analysis of trends, causes &

evaluations to design relevant interventions • Equity: rational use of foods to reach the

disadvantaged & high risk ages; targeted nutrition


Conclusion• Understanding what indicators & assessment

methods to use in policy & programs is key • Food & dietary adequacy (total energy &

diversity) is a necessary, but not sufficient condition for good nutrition

• Interpreting and presenting data in an accurate and relevant manner is essential

• Assessments that do not lead to actions are meaningless


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