informal consultation with member states and un agencies on a … · water • poor hygiene...
TRANSCRIPT
Reduce by 40% the number of
under-five stunted children
Adelheid Onyango
Technical Officer, Growth Assessment and Surveillance Unit
Department of Nutrition for Health and Development
Informal Consultation with Member States and UN Agencies on
A Proposed Set of Indicators for the Global Monitoring Framework for
Maternal, Infant and Young Child Nutrition
WHO/HQ, Geneva, 30 September – 1 October 2013
Outline
• Background for target – Definition – Rationale
• Logical framework linking the indicators • Proposed outcome indicators
– Strengths – Limitations – Data availability
• Proposed process indicators – Strengths – Limitations – Data availability
Background
• Stunting defined as length/height-for-age below -2 SD of the WHO standard median
• Results from cumulative deficits in linear growth caused by factors including inadequate feeding and/or repeated or chronic infections
• The most significant deficits are accumulated in the first 1000 days, from gestation to age 2 y
• After this age, stunting is largely irreversible
• The long term consequences of stunted growth include chronic diseases and economic losses
Agriculture and Food Systems
• Food production and processing
•Availability of micronutrient-rich foods
• Food safety and quality
Inadequate practices • Infrequent feeding • Inadequate feeding
during and after illness • Thin food consistency • Feeding insufficient
quantities • Non-responsive feeding
Health and Healthcare • Access to healthcare • Qualified healthcare
providers • Availability of supplies
•Infrastructure •Health care systems and
policies
Education • Access to quality education
• Qualified teachers • Qualified health educators • Infrastructure (schools and
training institutions)
Food and water safety • Contaminated food and
water • Poor hygiene practices • Unsafe storage and preparation of foods
Concurrent problems & short-term consequences Long-term consequences
Poor quality foods • Poor micronutrient
quality • Low dietary diversity and intake of animal-
source foods • Anti-nutrient content • Low energy content of
complementary foods
Water, Sanitation and Environment
• Water and sanitation infrastructure and services
• Population density •Climate change •Urbanization
• Natural and manmade disasters
Political economy • Food prices and trade
policy • Marketing regulations
• Political stability • Poverty, income and wealth
• Financial services • Employment and
livelihoods
Community and societal factors
Inadequate Complementary Feeding
Stunted Growth and Development
Health ↑Mortality
↑Morbidities
Developmental ↓Cognitive, motor,
and language development
Economic ↑Health
expenditures ↑Opportunity costs for care of sick child
Economic ↓ Work capacity
↓ Work productivity
Developmental ↓School
performance ↓ Learning capacity
Unachieved potential
Health ↓Adult stature ↑Obesity and associated co-
morbidities ↓ Reproductive
health
Infection
Clinical and subclinical infection
• Enteric infection: Diarrhoeal disease,
environmental enteropathy, helminths • Respiratory infections
• Malaria • Reduced appetite due
to infection • Inflammation
Household and family factors
Maternal factors • Poor nutrition during
pre-conception, pregnancy and lactation • Short maternal stature
• Infection • Adolescent pregnancy
• Mental health •IUGR and preterm birth • Short birth spacing • Hypertension
Inadequate practices • Delayed initiation • Non-exclusive breastfeeding
• Early cessation of breastfeeding
Context
Causes
Consequences
Society and Culture • Beliefs and norms
• Social support networks • Child caregivers (parental
and non-parental) • Women’s status
Home environment • Inadequate child
stimulation and activity • Poor care practices •Inadequate sanitation
and water supply • Food insecurity
• Inappropriate intra-household food
allocation • Low caregiver education
Breastfeeding
Actions to prevent stunting
• Improved maternal nutrition and health during pregnancy
• Appropriate infant and young child feeding with supplementation as needed
• Prevention (WASH, ITN use, immunization) and effective treatment of infections
Global trends – 1990 to 2012
Primary outcome indicator
Prevalence of low height-for-age in children <5
years of age defined as <-2 standard deviations
of the WHO Child Growth Standards median
Data availability
• Most nutrition surveys, e.g., MICS, DHS, SMART
and other national/sub-national surveys
Challenges
• Quality of measurements in routine data
• Multiple causes vs limited no. of indicators for the
framework
Agriculture and Food Systems • Food production and
processing •Availability of micronutrient-
rich foods • Food safety and quality
Inadequate practices • Infrequent feeding • Inadequate feeding
during and after illness • Thin food consistency • Feeding insufficient
quantities • Non-responsive feeding
Health and Healthcare • Access to healthcare • Qualified healthcare
providers • Availability of supplies
•Infrastructure •Health care systems and
policies
Education • Access to quality education
• Qualified teachers • Qualified health educators • Infrastructure (schools and
training institutions)
Food and water safety • Contaminated food and
water • Poor hygiene practices • Unsafe storage and preparation of foods
Concurrent problems & short-term consequences Long-term consequences
Poor quality foods • Poor micronutrient
quality • Low dietary diversity and intake of animal-
source foods • Anti-nutrient content • Low energy content of
complementary foods
Water, Sanitation and Environment
• Water and sanitation infrastructure and services
• Population density •Climate change •Urbanization
• Natural and manmade disasters
Political economy • Food prices and trade policy
• Marketing regulations • Political stability
• Poverty, income and wealth • Financial services
• Employment and livelihoods
Community and societal factors
Inadequate Complementary Feeding
Stunted Growth and Development
Health ↑Mortality
↑Morbidities
Developmental ↓Cognitive, motor,
and language development
Economic ↑Health
expenditures ↑Opportunity costs for care of sick child
Economic ↓ Work capacity
↓ Work productivity
Developmental ↓School
performance ↓ Learning capacity
Unachieved potential
Health ↓Adult stature ↑Obesity and associated co-
morbidities ↓ Reproductive
health
Infection
Clinical and subclinical infection
• Enteric infection: Diarrhoeal disease,
environmental enteropathy, helminths • Respiratory infections
• Malaria • Reduced appetite due to
infection • Inflammation
Household and family factors
Maternal factors • Poor nutrition during
pre-conception, pregnancy and lactation • Short maternal stature
• Infection • Adolescent pregnancy
• Mental health •IUGR and preterm birth • Short birth spacing • Hypertension
Inadequate practices • Delayed initiation • Non-exclusive breastfeeding
• Early cessation of breastfeeding
Context
Causes
Consequences
Society and Culture • Beliefs and norms
• Social support networks • Child caregivers (parental
and non-parental) • Women’s status
Home environment • Inadequate child
stimulation and activity • Poor care practices •Inadequate sanitation
and water supply • Food insecurity
• Inappropriate intra-household food allocation • Low caregiver education
Breastfeeding
PO1
IO1: malaria IO2: Diarrhea
PR1: Adequacy PR8: Diversity
PR2: Water PR3: Sanitation
PR4: ITN; PR5: ORS PR9: Immunization
PR6: dietary energy PR10: HH exp on food
Intermediate outcome indicators
Prevalence of malaria • In malaria endemic areas, elsewhere not relevant
• Data from WHO Global Health Observatory
Incidence of diarrhea in under-fives • Associated also with wasting
• Weak cross-sectional association with stunting
Median urinary iodine concentration (μg/L) in children aged 6-12 years • Proxy for HH consumption of iodized salt
• Link with growth questioned
• Different age group from the target population
Process indicators – I
Complementary feeding
• % 6-23 month-olds receiving a minimum acceptable diet
• Mean dietary diversity score (minimum diversity for 6-23 month-olds)
Data availability
• From DHS and MICS (UNICEF ChildInfo database)
• For adults HH food consumption surveys (FAO statistics)
Process indicators – II Household and family factors
• % population using an improved water source
• % population using improved sanitation facilities
• % households having access to iodized salt
• % population below minimum dietary energy consumption
• Average household expenditure on food of the bottom three deciles
Data availability
• WHO Global Health Observatory (World Health Statistics)
• MICS (UNICEF)
• FAO HH Food consumption surveys
Process indicators – III
Community and societal factors: health and healthcare
• Children sleeping under insecticide-treated nets
• % under fives with diarrhea receiving ORS
• Immunization coverage levels
Data availability
• Global Health Observatory (World Malaria Report)
Process indicators – IV
Challenges
• Data from varied sources and sectors, may not
always be accessible
• Sampling frames for the various surveys may not overlap to allow for attribution
• Survey data from non-overlapping periods may
limit plausibility of associations between
processes and outcomes
• Within-country disparities not evident from national
statistics