Lalita Bhattacharjee
Nutritionist
National Food Policy Capacity Strengthening Programme
Food and Agriculture Organization of the United Nations
Bangladesh
Presented on 2 July 2011
at the
Training Workshop on “Food Security Concepts, Basic Facts and
Measurement Issues” 25 June to 7 July 2011
Introduction
 Nutrition through the life stages
 Dietary energy and nutritional requirements in:

Infancy - birth to 1 year
 Childhood and adolescence
 Pregnancy and lactation
 Intergenerational effects
 Diet, energy and nutritional requirements in
adulthood
 Nutrition during ageing and the elderly

Operational Plan Indicators
 Life cycle approach
 Conclusion

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


Diets in all cultural variety define to a large
extent people’s health, growth and
development
Advances in research, expansion of
knowledge in prevention and control of
chronic diseases
Return to the concept of basic life course –
continuity of human life from fetus to old age
Need to address both undernutrition and
overnutrition



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

Nutritional status is internationally recognized as an indicator
of national development
Nutrition is both an input and an output/come of the
development process
A well-nourished population is essential for productive work
force and development
◦ people need food, health and care to be well-nourished
Two processes:
◦ on the one hand food security policies
◦ on the other sustainable livelihoods, right to food and
nutrition policies
…with different partners
The food, agriculture and health sectors is responsible for
food and nutrition security
MATERNAL, CHILD AND HOUSEHOLD NUTRITION


Intra uterine growth retardation (IUGR)
Premature delivery of a normal growth
for gestational age fetus

Overnutrition in utero

Intergenerational factors





Dietary, energy and nutritional requirements
All neonates typically lose some weight after
birth
Pre term infants are born with more extra
cellular water than term infants and thus lose
more weight than term infants
Post natal loss should not be excessive.
Loss of 15-20% of birth weight can lead to
dehydration – inadequate fluid intake or
tissue wasting from poor energy intake
What defines Infancy?
The first year of life.
Why are the nutrient
needs of an infant so
high?
Infants grow at
accelerated rate:
double birth weight by
6 months; triples by 12
months of age
5.00%
4.37%
Mortality Rate
4.50%
4.00%
3.50%
3.00%
2.34%
1.90%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
Exclusive breast fedding
Predominant Feeding
Source:Arifeen et al, 2001
No breast feeding
New International Child Growth Standards for
infants and young children released on 27 April
2006
⇛ A community based study “The Multicentre
Growth Reference Study (MGRS)’’ undertaken
by WHO & United Nations University
⇛ More than 8000 children followed after every 3
months from Brazil, Ghana, India, Norway,
Oman and USA
Monitoring infant growth:
◦ Infants not receiving adequate nutrition may have
difficulty reaching milestones
◦ Failure to thrive (FTT): delayed in physical growth or
size or does not gain enough weight
◦ Growth charts track physical development.

Head circumference, length, weight, and weight for length
measures are used to assess growth
Infants have specific calorie, iron, and other
nutrient needs.
 108 calories/kg of body weight for first 6 months
 9.1 g protein/day first 6 months, 11 g/day second
6 months
 Fat should not be limited.
 Vitamin K injection needed due to sterile gut
 Iron-enriched cereals/home based foods should
be introduced at 6 months.

Complementary foods
◦ Not recommended to give any solid foods before 6
months

When to begin
About 6 months of age
Iron and zinc stores depleted
Look for physical signs
Loss of extrusion reflex

Nutrient-dense foods
Solid foods should be introduced
gradually to make sure child isn’t allergic or
intolerant
◦ One new food per week
◦ Rice cereal is great first food: least allergy-causing
◦ Other grains, then vegetables, fruits over a period of
months
Homemade or store-bought baby food?
◦ Homemade is cheaper, but can also find high-quality
store-bought foods without added sugar, salt,
preservatives
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



Implementation of comprehensive policies by
the Government
Full support for two years of breastfeeding or
more
Promotion of timely, adequate, safe and
appropriate complementary feeding
Guidance on IYCF in especially difficult
circumstances,
Legislation or suitable measures giving effect
to the International Code
Year
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
(% of children under five)
Prevalence of underweight
Africa
80
Asia
70
60
Bangladesh
50
India
40
Nepal
30
20
Pakistan
10
Sri Lanka
0
Country
and yr
H/A
%<-2
SD
H/A
%<-3
SD
W/H
%<-2
SD
W/H % <
- 3 SD
W/A % <
- 2SD
W/A % < 3SD
Bangladesh
2007
M
F
43.7
42.7
16.5
15.8
18.4
16.5
3.3
2.5
39.9
42.1
11.4
12.1
India
2005 -06
M
F
48.1
40.0
23.7
23.4
20.5
19.1
6.8
6.1
41.9
43.1
15.3
16.4
Nepal
2006
M
F
49.0
49.6
19.5
20.8
12.9
12.3
3.1
2.2
37.5
39.7
10.1
11.2
Region
Country
Lowest
2nd
3rd
4th
Highest
South Asia
Bangladesh
59
53
45
43
30
India
61
54
49
39
26
Pakistan
54
47
43
37
26
Benin
29
30
23
20
10
Burkina Faso
42
40
41
39
22
Ethiopia
49
51
51
45
37
Mozambique
31
28
26
19
9
Rwanda
27
30
28
24
14
Tanzania
25
26
22
20
12
Uganda
27
26
25
19
12
Africa
Source: Gwatkin et al, Country Reports on HNP and Poverty: Socio-Economic Differences in Health, Nutrition, and Population, April 2007
Is Malnutrition in South Asia Really Worse than in Africa?
Quintile
H/A
% < - 2SD
H/A % < 3 SD
W/H % < 2 SD
W/H % < 3 SD
W/A % < 2SD
W/A % < 3 SD
Lowest
54.0
23.2
20.8
3.8
50.5
15.1
Second
50.7
20.4
17.8
2.8
45.9
15.8
Middle
42.0
15.2
16.9
2.6
41.0
11.2
Fourth
38.7
11.8
17.6
2.8
38.1
8.9
Highest
26.3
13.2
13.2
2.0
26.0
6.5
Age group
Category
Body weight
kg
Kcal/d
Kcal/kg/d
Infants
0-6 mo
6-12 mo
5.4
8.4
500
670
92
80
Children
1-3 y
4-6 y
7-9 y
12.9
18.1
25.1
1060
1350
1690
82
75
67
Boys
10-12 y
34.3
2190
64
Girls
10-12 y
35.0
2010
57
Boys
13-15 y
47.6
2750
58
Girls
13-15 y
46.6
2330
50
Boys
16-17 y
55.4
3020
55
Girls
16-17 y
52.1
2440
47

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
Association between low growth in childhood
and increased risk of CHD, irrespective of
size at birth
Postnatal factors shaping disease risk
Growth rates of infants in Bangladesh (most
of whom had chronic IUUN and were breast
fed, were similar to growth rates of breast fed
infants in industrialized countries
Catch up growth was limited and weight at 1
yr was a function of birth weight


LBW babies have characteristic poor muscle but
high fat preservation ( so called thin fat babies)
This phenotype persists throughout post natal life
and is associated with increased central adiposity
in childhood that is linked to ↑ risk of raised BP and
disease

Association between LBW and high BP and BMI –

Relative weight in adulthood and weight gain

importance of weight gain after birth
associated with ↑ risk of cancers
Height serves partly as an indicator of socio
economic and nutritional status in childhood
(energy and protein intake)




Secondary sexual characteristics emerge, with
onset of menarche (periods) in girls and
semenarche (production of semen) in boys
Physical developments are accompanied by marked
changes in psychological and emotional make up,
characteristic of ‘teenage’ behaviour
Adolescence begins approx 2 years earlier in girls
than boys, with acceleration of growth of muscle in
boys and deposition of adipose tissue in girls
According to WHO, 10 to 18 y is the period of
adolescence
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Adolescent boys experience rapid muscular growth
and engage in more physical activities than girls so
they need more energy foods
Adolescent girls, because of menstruation, need
more iron than boys
Iron is essential for building and maintaining blood
supplies ad giving the blood its red colour
Girls should take more iron rich foods such as liver,
egg yolk, lean meat, green leafy vegetables, dried
beans, dried fruits and unpolished rice and whole
wheat
Age
group
BW kg
Gain BW
kg/y
Boys
34.3
3.5
Girls
35.0
3.7
47.6
46.6
55.4
52.1
Basal
loss
mg/d
Blood
volume
mg/d
Muscle
mass
Mg/d
Store
Mg/d
Blood
loss
Mg/d
Total
reqmt
Mg/d
-----
1.05
0.28
1.33
10-12 y
13-15 y
Boys
Girls
16-17 y
Boys
Girls
0.49
0.27
0.13
0.16
4.2
1.7
0.66
0.65
0.39
0.13
0.15
0.06
0.40
0.15
---0.37
1.60
1.36
1.5
0.78
0.73
0.14
----
0.05
----
0.40
0.15
---0.42
1.37
1.30
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Development of risk factors

Tracking of risk factors (in terms of prevention)



Development of healthy/unhealthy habits that tend
to stay throughout life (physical inactivity)
Older adolescents (habitual alcohol, tobacco use
associated with risks of ↑ BP and related risks
Syndrome X ( physiological disturbances, hyper
insulinemia, impaired GT, HT, ↑ TG and ↓ HDL





Weight gain during pregnancy is an indicator of
nutritional status of pregnant women
A weight gain of 11 -13 kg during the pregnancy
term is ideal
According to various studies, weight gain during
pregnancy in Bangladeshi mothers is only 7-9 kg
indicative of poor nutritional status of the mother
and poor growth of the fetus
The fetus is born with LBW ( < 2.5kg)
Over a third (36%) of babies in Bangladesh are born
with LBW
Rate of
tissue
deposition
1st trimester
(g/d)
2nd trimester
(g/d)
3rd trimester
(g/d)
Total
deposited
(g)
17
60
54
12,000
Protein
deposited
0
1.3
5.1
597
Fat
deposited
5.2
18.9
16.9
3741
Weight gain
Average of
2nd and 3rd
trimesters
12 kg increase
375 kcal
10 kg increase
310 kcal
NIN/ICMR (2010) Nutrient requirements and RDA for Indians


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
Lactation is the period when the mother feeds her
baby through the breast.
On an average 600-800 ml/d milk is produced by a
nursing mother
Approximately 1kcal of energy is needed to
produce 1 ml of milk
Malnutrition during pregnancy is likely to continue
after birth of the baby if the mother is poorly
nourished; a malnourished mother cannot breast
her baby adequately
Malnutrition affects the volume of milk produced if
not its quality
Age group
Man
Woman
Category
Body weight
(kg)
Requirement
Kcal/d
kcal/kg/d
Sedentary
60
2320
39
Moderate
60
2730
46
Heavy
60
3490
58
Sedentary
55
1900
35
Moderate
55
2230
41
Heavy
55
2850
52
Pregnant
55+ GWG
+ 350
Lactation
55 + WG
+ 600
+ 520
Women of reproductive age:



The reproductive age in Bangladeshi mothers
is considered as 15 to 44 years
CED in women of reproductive age is
measured by height and BMI
Height < 145 cm and BMI < 18.5 kg/m² is
indicative of chronic CED
0.50
Weight for age Z-score (NCHS)
0.25
Latin America and Caribbean
0.00
Africa
-0.25
Asia
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
0
3
6
9
12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age (months)
Repositioning Nutrition, 2006
Mean height for age z-scores by age relative to the new WHO reference
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
58
55
52
49
46
43
40
37
34
31
28
25
22
19
16
13
10
7
4
1
-2.25
-2.5
Age (months)
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)
Health
environm
Women's
education
43%
ent
19%
National
Women's
food
status
availabilit
12%
y
26%
Contributions to reductions in
child malnutrition, 1970-95
Source: Smith and Haddad 2000




To what extent risk factors continue to
influence development of CD
To what extent will modifying such risk
factors make a difference in the emergence
of disease
What is the role of risk factor reduction and
modification in secondary prevention and the
treatment of those with disease
Adult phase of life –disease expressed,
critical time for preventive reduction of risk
factors and increasing effective treatment







Most chronic diseases will be manifested in later stages of
life
Absolute benefits in changing risk factors and adopting
health promoting behaviours (exercise and healthy diets)
Maximize health by avoiding /delaying preventable
disability
Along with societal and disease transitions, major
demographic shifts
Older people defined above 60 y
Average life expectancy increased from middle of last
century
Majority of elderly will be living in the developing world









Disease
Eating poorly
Tooth loss/Mouth pain
Economic hardship
Reduced social contact
Multiple medicines
Involuntary weight loss/gain
Needs assistance in self care
Elder years above age 80




Reduced need for calories
More prone to disease due to lowered food
intake, physical activity and resistance to
infection
Good food habits and regular exercise
minimize the ill effects of ageing
Need for more calcium, iron, zinc, VA and
anti oxidants to prevent age related diseases
Note: Variety of nutrient rich foods, match food intake with physical activity, eat
food in many divided portions/d, avoid fried, salty and spicy foods and
exercise regularly
• Confirms importance of first 2 years of life as a critical window within which child
growth is most sensitive to environmentally modifiable factors
• Monitoring length/height (in addition to weight) seems essential because faltering
patterns are clearly different for HAZ and WAZ, and short stature is associated with
deleterious long-term outcomes
• Reveal
a much greater problem of undernutrition during the first 6 months of life
than previously understood (shorter “window of opportunity”) with possibly even
higher levels of intrauterine growth retardation emphasizing the need for even greater
need for prenatal and early-life interventions, including preventing low birth weight
and promoting appropriate infant feeding practices
• Suggests that BMI gain after 6 months of age increases adiposity but not height at
5years – hence potentially negative implications for NCDs in adulthood
Percent
children
LBW
Slide courtesy of John Newman, SAR (2010)
Source: WB World Development Indicators, Latest available data for each country, GDP PC PPP, constant int’l 2005 $



GDP losses  2-3%
Leads to a >10% potential reduction in lifetime earnings for
each malnourished individual
Malnutrition (stunting) in early years linked to a
 4.6 cm loss of height in adolescence
 0.7 grades loss of schooling
 7 month delay in starting school
(Improved nutrition can be a driver of economic growth)
Repositioning Nutrition, 2006
Dietary factor
Goal (% of total energy )
Total fat
15-30%
Saturated fat
< 10%
PUFA
6-10%
Trans fatty acids
< 1%
Total CHO
55 -75%
Free sugars
10%
Protein
10-15%
Cholesterol
<300mg/d
Na Cl
<5g/d
Fruits and vegetables
at least 400 g/d
Total dietary fibre
From foods (40g/d)
Non starch polysaccharides (NSP)
From foods (whole grains, F&V)
20g/d
Three child well being outcomes :


Mothers and children are well nourished
(measured by rates of stunting and anemia)
Mothers and children are protected from
infection and disease (measured by rates of
malaria/illness, care seeking for treatment of
diarrhea and ARI and immunization rates)

Mothers and children access essential health
services (measured by rate of skilled
attendance at birth and antenatal coverage)
Objective
Baseline
Target 2016
↓ in prevalence of LBW ( < 2.5
kg)
22% (SOWC, 2009)
15%
↓ in the prevalence of UW (WAZ <
-2 Z scores ) in children < 5 y
41% (BDHS, 2007)
34%
↓ in prevalence of stunting (HAZ
< -2 Z scores
43% ( BDHS, 2007)
38%
↓ in prevalence of wasting (WHZ
< -2 Z scores ) in children < 5 y
17 % (BDHS, 2007)
10%
↓ in XN among pregnant women,
lactating women and children
aged 12 -59 mo)
2.4 %; 2.7%, 0.04 %
(IPHN/UNICEF/HKI, 2005)
< 1%
↓ in the prevalence of anemia in
< 5 y child, adolescents and in
pregnant women
Children < 5 -48%
Adolescent girls 30%
Pregnant women 46%
(National Anemia survey 2001 3)
23%
↓ in prevalence of I deficiency
(UIE < 100 mcg/L of school age
6-12 y children)
34.6% (IDD survey 2005)
23%
↑ in rate of EBF in infants under
< 6 mo
43% (BDHS, 2007)
50%
↑ in the rate of 6-24 mo children
fed minimum acceptable diet
42% (BDHS, 2007)
52%
Indicators
Unit measurements
Base line (with yr
and data source)
Mid 2014
Projected target
Mid 2016
(1)
(2)
(3)
(4)
(5)
Prevalence of XN
among < 5 y
% children
0.04% NSP 2006
<1%
< 1%
% of children 6-59 mo
receiving VA
% children
88.3% BDHS 2007
90%
> 90%
% of VA
supplementation in
post partum women
% PP women
19.5% BDHS 2007
50%
> 90%
Rate of EBF in infants
under < 6 mo
% children
43% BDHS 2007
47%
50%
% children 6-23 mo fed
minimum acceptable
diet
% children
41.5% BDHS 2007
48%
52%
Prevalence of anemia
among pregnant
women
% pregnant women
46% National Survey
2001
40%
35%
Prevalence of anemia
among children 6-59
mo
% of children
48% National Survey
2001
40%
35%
Prevalence of iodine
deficiency
% of school age
children
34.6% IDD survey 2005
30%
23%
# of MOs trained in
nutrition services
delivery
No of MO in UHC
0
578 (60%)
964 (100%)
# CC workers trained in
nutrition services
delivery
No of HA, FWA and CHP
0
27,000 (60%)
40,500 (100%)
% of UHCs having a
functional nutrition
corner established
# of Upazila Health
Complexes
21
120 (60%)
200 (100 %)





Unhealthy diets, physical inactivity and smoking are
confirmed risk behaviours for chronic diseases
Biological risk factors of HT, obesity and lipidemia are firmly
established as risk factors for CHD, stroke and diabetes
Nutrients and physical activity influence gene expression and
may define susceptibility
Major biological and behavioral risk factors emerge and act in
early life and continue to have a negative impact throughout
the life course
Major biological factors can continue to affect the health of
the next generation





Globally, trends in the prevalence of many risk factors are
upwards especially for obesity, physical inactivity and in the
developing world particularly, smoking
Selected interventions are effective but must extend beyond
individual risk factors and continue throughout the life course
Some preventative interventions early in life offer life-long
benefits
Improving diets and increasing levels and increasing levels of
physical activity and older people will reduce chronic disease
risks for death and disability
Secondary prevention through diet and physical activity is a
complementary strategy in retarding the progression of
existing chronic diseases and decreasing mortality and the
disease burden from such diseases
Determinants of Child Nutrition and Interventions to Address them
Nutrition
specific
interventions
Interventions
- Infant and young child
nutrition and treatment of
severe undernutrition
- Micronutrient
supplementation &
fortification
- Hygiene practices
- Agriculture & food security
- Health Systems
- Soc. Protection/safety nets
- Water & sanitation
- Gender & Development
- Girls’ Education
-Climate change
- Poverty reduction &
economic growth programs
-Governance, stewardship
capacities & management
-Trade & patents (&role of
private sector)
- Conflict Resolution
- Environmental Safeguards
Adapted from UNICEF 1990
Food/nutrient
intake
Access to
food
Health
Maternal
and childcare
practices
Water/
Sanitation
Health
services
Immediate
causes
L
O
N
G
Basic causes
ECONOMIC STRUCTURE
RESOURCES
ENVIRONMENT, TECHNOLOGY, PEOPLE
R
O
U
T
E
S
Underlying
causes
INSTITUTIONS
POLITICAL & IDEOLOGICAL FRAMEWORK
S
H
O
R
T
Nutrition
sensitive
interventions
R
O
U
T
E
S