Food & Nutrition Situation
in Bangladesh
Dr Tahmeed Ahmed
Director
Centre for Nutrition & Food Security
ICDDR,B
Professor, Public Health Nutrition
James P. Grant School of Public
Health, BRAC University
Intergenerational Cycle of Malnutrition
Higher
mortality
rate
Impaired
mental
development
Baby
Low Birth
Weight
Untimely / inadequate
weaning
Frequent
infections
Inadequate
food, health
& care
Foetal
Malnutrition
Child
Stunted
Malnourished
Reduced
mental
capacity
ADULTS
Pregnancy
Low Weight
Gain
Adolescent
Stunted
Higher
maternal
mortality
Reduced
mental
capacity
Llanos, Alvear, Uauy 2004
Different Types of Childhood Malnutrition
Children
Normal height for age
Normal
Wasted
Stunted
Underweight
Low weight for height
Low height for age
Low weight for age
Stunting in Early Childhood & Later
Development Outcomes
Philippines, n=2489
58
56
Not stunted
Mildly stunted
54
Moderately/severely
stunted
52
50
48
46
Cognitive score at 8 y
Mendez MA, 1999
UNICEF; Black R, 2008
Percentage below -2SD
NCHS/WHO Reference
Trends in Prevalence of Underweight in
Under-5 Children in Bangladesh
80
70
60
50
40
30
20
10
Ahmed T et al. In press.
Percentage below -2SD
NCHS/WHO Reference
Trends in Prevalence of Underweight in
Under-5 Children in Bangladesh
80
70
60
50
40
30
Reasons for20
the decline:
Increased literacy
10
Fertility rate reduced
Measles vaccination now at 83%
Family size smaller
Vitamin A supplementation coverage at 88%
Rural electrification
Increased food production & energy intake
Microcredit?
Ahmed T et al. In press.
Percentage below -2SD
NCHS/WHO Reference
Trends in Prevalence of Underweight in
Under-5 Children in Bangladesh
80
70
60
50
40
30
20
10
Ahmed T et al. In press.
Percentage below -2SD
NCHS/WHO Reference
Trends in Prevalence of Underweight in
Under-5 Children in Bangladesh
80
70
60
50
40
30
Assumptions
20on reasons for the stagnation:
• Increase in
10inequity (increase in Gini coefficient)
• Reduction in infant mortality rate resulting in more infants surviving but
with malnutrition
Ahmed T et al. In press.
Percentage below -2SD
NCHS/WHO Reference
Trends in Prevalence of Underweight in
Under-5 Children in Bangladesh
80
70
60
50
40
30
20
Required rate of reduction, 1.36 percent points/yr
10
Rate of reduction so far, 1.27 percent points/yr
Ahmed T et al. In press.
Malnutrition is more common in Asia
than in Sub-Saharan Africa
Percentage below -2SD
NCHS/WHO Reference
60
50
40
47.0
47.8
44.9
35.6
38.5
30
22.6
20
10
0
20.2
Trends of BMI of Women in Bangladesh
Percent of women with BMI <18.5
60
52.0
50
45.4
40
34.3
29.7
30
20
10
0
1996-97
1999-2000
2004
2007
On the Causes of Malnutrition
Population increases in a
geometric ratio, while the means
of subsistence increases in an
arithmetic ratio
Thomas Malthus (1766-1834)
Limited Land Mass with the Highest
Population Density
Population Density (/ sq.km.)
1200
Population density in
Bangladesh is 3 to 40
times higher than
other ‘mega’ countries
Bangladesh
1000
800
600
Japan
400
Pakistan
200
China
USA
0
Nigeria
0
Mexico
200
Russia
400
Brazil
India
Indonesia
600
800
Population (millions)
1000
1200
1400
Korail Slum
• Close to 27% or 40 million live in urban areas
• About 40% of Dhaka city population lives
in slums
• Dhaka is the fastest growing city
Korail Slum
On the Causes of Malnutrition
Famine and malnutrition
are a result of a collapse
of entitlements for a
certain segment of
society and the failure of
the state to protect those
entitlements.
Amartya Sen
• Poverty
• Food insecurity
• Poor maternal nutrition
• Low birth weight
• Low rates of EBF
• Lack of proper CF
• Frequent illnesses
BBS, World Bank, WFP 2005
Food Security in Urban Slums
Household
consumption
Dhaka
Chittagong Khulna Rajshahi All
<2,122
kcal/person/d
42.4
56.0
52.0
61.3
47.8
<1,805
kcal/person/d
24.2
35.8
38.5
36.0
29.0
Urban food security Atlas, 2008
Share of Energy Intake in Bangladesh
Staples
Non-staple
plants
Fish and
animal
Howarth Bouis, 2006
Underweight (BMI <18.5)
Over weight (BMI ≥25)
Diabetes mellitus
Hypertension
- Carbohydrates in diet
- ‘Fast food’ culture
- Lack of exercise
Slum
Non-slum
26.7
14.8
5.5
12.1
12.9
34.2
17.0
21.4
Severe Acute Malnutrition
2.9% in Bangladesh
~500,000 children
At risk of death from
•
•
•
Hypoglycemia
Hypothermia
Infections
Admission
2 weeks
A 2 yr old girl with
dysentery, pneumonia
Weighed only 3.8 kg
4 weeks
5 weeks
Treated with
• therapeutic diets
• antibiotics
• micronutrients
Diagnosed TB and
treated appropriately
Timeliness: Early Versus Late
Presentation
There has been some improvement
but much more is required
The Lancet Series on Maternal
and Child Undernutrition
Evidence-Based Interventions
Systematic review
of efficacy or
effectiveness of 45
possible
interventions that
affect maternal and
child undernutrition
and nutrition-related
outcomes, including:
• Breastfeeding promotion
• Complementary feeding promotion
strategies with or without provision
of food supplements
• Micronutrient interventions
(fortification & supplementation)
• General supportive strategies for
improving family and community
nutrition and disease burden
reduction
• Interventions for the treatment of
severe acute malnutrition
Bhutta ZA, Ahmed T et al. Lancet 2008
Interventions with Sufficient Evidence to
Implement in All Countries
Maternal and Birth
Outcomes
• Iron folate
supplementation
• Maternal supplements of
multiple micronutrients
• Maternal iodine through
iodization of salt
• Maternal calcium
supplementation
• Interventions to reduce
tobacco consumption or
indoor air pollution
Newborn Babies
Infants and Children
• Promotion of
breastfeeding (individual
and group counseling)
• Promotion of
breastfeeding (individual
and group counseling)
• Behavior change
communication for
improved complementary
feeding
• Zinc supplementation
• Zinc in management of
diarrhea
• Vitamin A fortification or
supplementation
• Universal salt iodization
• Handwashing or hygiene
interventions
•Treatment of SAM
Bhutta ZA, Ahmed T et al. Lancet 2008
Interventions with Sufficient Evidence to
Implement in All Countries
Maternal and Birth
Outcomes
• Iron folate
supplementation
• Maternal supplements of
multiple micronutrients
Newborn Babies
• Promotion of
breastfeeding (individual
and group counseling)
• Maternal iodine through
iodization of salt
• Maternal calcium
Hygiene interventions:
supplementation
• Interventions Reduce
to reduce incidence of diarrhea
tobacco consumption or
reduce odds of stunting
indoor air pollution
Infants and Children
• Promotion of
breastfeeding (individual
and group counseling)
• Behavior change
communication for
improved complementary
feeding
• Zinc supplementation
• Zinc in management of
diarrhea
by
30%,
• Vitamin A fortification or
supplementation
• Universal salt iodization
• Handwashing or hygiene
interventions
•Treatment of SAM
Bhutta ZA, Ahmed T et al. Lancet 2008
Evidence-Based Interventions
Interventions showing the most promise for
reducing child deaths and future disease burden
include:
•
•
•
•
Breastfeeding promotion
Appropriate complementary feeding
Supplementation with vitamin A and zinc
Appropriate management of severe acute
malnutrition
Bhutta ZA, Ahmed T et al. Lancet 2008
Coverage is most important !
Reduction
in deaths
Reduction
in stunting
99% coverage
25%
35%
% of
DALYs
averted
25%
90 % coverage
22%
32%
23%
70 % coverage
17%
27%
17%
Bhutta ZA, Ahmed T et al. Lancet 2008
To eliminate stunting in the longer term, these
Interventions should be supplemented by improvements
in the underlying determinants of undernutrition, such as
poverty, poor education, disease burden, and lack of
women’s empowerment.
Recommendations
• Business as usual will not work
• Need to think out of the box now
• There is no one size that fits all, several
strategies need to be tried
Recommendations
• Immediate need is to improve existing
services and scale them up
– Primary health care focusing on child & maternal
health and nutrition should be priority
– Increase number of centers, staff
– Improve quality of counseling
– Rigorous monitoring of quality of services to
reduce dissatisfaction with existing services
Recommendations
• Primary health care intervention package should
be expanded and improved
– IFA tablets for adolescent girls, PLW
– Breastfeeding & complementary feeding
– Micronutrient powder for infants & young children
– Management of moderate & severe acute
malnutrition
Undernutrition hotspots need special attention
– Monga-prone areas in the north
– The coastal belt and char areas
– Areas in Chittagong & Sylhet divisions with
higher prevalence of child malnutrition
– Rat-infested areas in the Hill Tracts
Recommendations
• But the ultimate goal is to prevent/control rapid
unplanned urbanization
– Create livelihoods in rural Bangladesh
– Control population growth drastically
– Improve livelihood & living conditions of people who
are already living in urban areas