Prevention of stunting- a
development challenge;
food/nutrient based approaches,
the way forward
Dr. Khizar Ashraf
United Nations, World Food Programme
Intended Discussion
• Nutrition Status of Under 5 Children in
Pakistan and the issue of food insecurity
• Why Malnutrition Matters
• The window of opportunity (1000 days)
• Prevention of Stunting possible food based
approaches
• Ongoing Evidence building in Pakistani context
Malnutrition responsible for about 1500 deaths
globally, mostly women, infants and
children, during this presentation!
•These deaths are preventable!
Some Major World Risk Factors Causing Deaths
Some WHO Major Risk Factors Causing World Deaths in 2000
Risk Factor
Occupational safety
Unsafe water,
sanitation, hygiene
Alcohol
Unsafe sex
Tobacco
Malnutrition
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
Number of Deaths (X1000)
(World Health Report, 2002)
Malnutrition accounts of ≈ 30 million
deaths per year (about 1 death per second)
Death
Figure from WHO, 2000
The Issue < 5 Indicators
NNS 2011
Percentage of < 5 children with different types of Malnutrition
60
52.2
49.8
47.8
50
43.6
40.5
39.6
40
39.2
31.5
29.8
30
20
31.7
25.8
24.1
17.6
17.5
15.1
16.1
17.2
Pakistan Overall
Balochistan
Khyber Pakhtunkwa
13.6
10
0
Sindh
Punjab
AJK
Provinces / Administrative Areas
Stunted
Wasted
Underweight
• 32.7%, 30.3% and 40 % are suffering from Iron, Vitamin A and Zinc deficiency
respectively, where as 62.5% are anemic
Micro-Nutrient Deficiency among children,
Pakistan ( NNS 2011)
61.9%
54.1%
40%
IronAnemia
Defficiency Anemia
VitaminA
A defficiency Vitamin
Vit D
Vitamin
Ddefficiency Zinc
39%
Zink Defficiency
Micro-nutrient Deficiency: Iodine
• Adequate level of iodine
status at national level
documented in NNS 2011.
Median Urinary Iodine level of children
between 6-12 years and Universal Salt
Iodization (USI), Pakistan
126
• Significant improvement
in the use of Iodized Salt in
2011 compared to the
result of 2001 NNS.
• Yet Pakistan lags behind
the international USI
target coverage of 90% and
above.
100-199
90%
69%
17%
Target
Median
Urinary
Iodine
Median
Urinary
Iodine (NNS
2011)
Target USI
% USI NNS % USI NNS
2001
2011
Why Malnutrition Matters
Why Malnutrition Matters
10
The Outcome: Vicious Cycle of Poverty
and Malnutrition- Estimated effect on
Pakistan
Income poverty
Low food
intake
Frequent
infections
Hard
physical
labor
Frequent
pregnancies
Large
families
Malnutrition
Direct loss in productivity
from poor physical status
Indirect loss in productivity
from poor cognitive
development and schooling
Loss in resources from
increased health care costs
of ill health
Overall loss to the economy of 2-3% of GDP annually
Evidence shows the “window of opportunity” is small…with a large part of the
damage happening before and shortly after birth…
Mean height for age z-scores by age
By region (0-59 months)
1.5
1.25
1
0.75
EURO
PAHO
EMRO
SEARO
AFRO
Z-scores (WHO)
0.5
0.25
0
-0.25
-0.5
-0.75
-1
-1.25
-1.5
-1.75
-2
Why Malnutrition Matters
58
55
52
49
46
43
40
37
34
31
28
25
22
19
16
13
10
7
4
1
-2.25
-2.5
Source: Victora CG, et al. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health
Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print)
Age (months)
12
Nutrition and Early Childhood
Development
Abnormal Brain Development Following Sensory Neglect in Early
Childhood.
Source: Perry (2004)
Major contributing factors in Pakistan
– Inappropriate IYCF practices; late initiation breast
feeding - only 37% exclusively breastfed.
– Household food insecurity is 58% country wide, 72% in
Sindh
– Household income minimal - subsistence
– Poor quality and insufficient amount clean water
– Poor sanitation - 48 million people practice open
defecation
– Early and frequent childbearing (50% of girls are
married by the age of 18 years, 15% by the age of 15, PDHS 200607)
– Low literacy rate - 47%
– Frequent emergencies
Challenge
Why to engage in Prevention of Stunting
How to move towards prevention of
stunting
Prevention of stunting project Thatta- Sajawal:
utilizing the window of opportunity for
addressing stunting in children under 5
Objectives of the Project
• To reduce stunting in children 6-23 months using a locally
produced LNS type (Wawamum) and promoting
appropriate IYCF practices (including promotion of exclusive
breast feeding until 6 months).
• To reduce micronutrient deficiencies in children 24-59
months using multi micronutrient powders, MNP,, along
with appropriate behavior change communication.
• To improve maternal/PLW nutritional status and to have an
impact on the birth outcome (reduce low birth weight),
• To study effectiveness of food based approach to address
stunting Lipid- based nutrient supplement
Evidence Building in Pakistani
Context: Research component
• To assess the effectiveness of the food/nutrient -based
interventions on reduction of stunting among children under two.
• To assess the design and operational factors at the different stages
of the programme cycle that may have affected the outcome.
• To determine unintended consequences of the interventions, both
positive and negative.
• To determine cost-effectiveness.
• To provide recommendations for improved programme design and
evaluation.
• To know the optimal length of preventive intervention.
• To compare the use of specialized nutritious foods over other
interventions, such as conditional cash transfers for stunting
prevention.
24
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Scaling up nutrition in Pakistan through multisectoral action