Sanghvi 9 linking dietary intakes with nutritional assessment

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 33

Outcome/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 14

Food 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, evaluatepast 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/CV

dietary 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/CV

dietary 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

1991-92 886 938 878

1995-96 914 931 911

2005 949 952 946

2010 1000 985 1005


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

Food available in grams per head per day

800

850

900

950

1000

1050

1991-92 1995-96 2005 2010

All

Urban

Rural


Diversity:-National supplies-Household level

- Child’s diet-Women’s diet


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

Food Recom. 2005 2010 Trend

Rice 390 440 416

Wheat 100 12 26

Vegetables 225 220 236

Pulses 30 14 14

Oil 20 16 21

Fish 45 42 49

Meat/eggs 34 20 25


Content of food basket: improving diversity

0

50

100

150

200

250

300

350

400

450

500

2005 2010

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

13.88

35.38

39.28

19.18

46.3944.52

22.99

47.32 47.07

23.14

53.29

49.88

0

5

10

15

20

25

30

35

40

45

50

55

Vietnam Bangladesh Ethiopia

PER

CEN

T ST

UN

TED

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

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

Bivariate

Food secure

Mildly food insecure

Moderate food insecure

Severely food insecure


Factors that determine nutritional status


Adequate Complementary Feeding

38 3847 44 48

16

36

4858

0

10

20

30

40

50

60

70

80

90

100

Lowest Second Middle Fourth Highest 6-8m 9-11m 12-17m 18-23m

By Wealth Quintiles By Age Groups

BDHS 2007

Quality of Children’s Diets (BDHS, 2007)

0 0 210

24

34

48

6471

75

0

10

20

30

40

50

60

70

80

90

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

• Importance of under 2’s


Illustration of association between dietary adequacy and anthropometry

1008020Total sample

70700% > -2SDs

301020% <-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

100

200

300

400

500

600

700

800

900

1000

0-2 3-6 7-8 9-11 12-23

Calo

ries p

er

day

Age in months

Energy Required & Amount From Breastmilk & CF

Compl. Food

Breastmilk200 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 33

Outcome/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 14

Food 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

43 43

16

36

48

58

4347

68

0

10

20

30

40

50

60

70

80

90

100

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


Sanghvi 9 linking dietary intakes with nutritional assessment

Health & Medicine

Transcript of Sanghvi 9 linking dietary intakes with nutritional assessment