module 5: nutritional assessment in policy and programmatic application by tina g. sanghvi, phd...
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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
Module 5: Program and Policy Application, Tina Sanghvi PhD
Indicators – Country Investment Plan
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
•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
Module 5: Program and Policy Application, Tina Sanghvi PhD
Diversity:-National supplies-Household level
- Child’s diet-Women’s diet
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
Content of food basket: gaps in diversity
0
50
100
150
200
250
300
350
400
450
500
Recom.
2005
2010
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
Why improving food security does not necessarily remove undernutrition
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
Factors that determine nutritional status
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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:
Module 5: Program and Policy Application, Tina Sanghvi PhD
Indicators – Country Investment Plan
Module 5: Program and Policy Application, Tina Sanghvi PhD
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.
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD
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
Module 5: Program and Policy Application, Tina Sanghvi PhD