The critical period is shown in the circle. These data are using the new 2006 WHO Growth Standards and are drawn from developing country data.
This framework sets causes that operate at 3 levels:Immediateinadequate diet and disease, both of which can make each other worse this is referred to as the infection-malnutrition cycle.Underlying inadequate household food security; inadequate care; inadequate health services and an unhealthy household environmentBasic political, economic, legal and ideological factors (including religion, culture and tradition)Whereby factors at one level influence other levelsMain interrelated drivers of undernutrition:Food Availability of, access to and utilization or consumption of adequate quantities of safe good quality nutritious food is an important factor influencing nutritional statusHealth Infectious disease and inadequate diet act together, each aggravating the effects of the other to produce what is referred to as the "malnutrition and infection cycle".Care and feeding practices require time, attention and support and are essential to meet the physical, mental and social needs of individuals. An incomplete understanding of the body's nutritional needs and lack of knowledge of how to meet these needs with available foods can lead to malnutrition.
This slide shows the different determinants of nutritional status using an adaptation of the UNICEF framework for the causes of malnutrition. Improving productivity alone can’t immediately translate to improved nutrition outcomes for a variety of reasons. However, if we tackle the problem from various angles for the SAME households, we can achieve success.The immediate determinants are food/nutrient intake and health. Proper food consumption provides the necessary nutrients humans require for healthy growth, development and day to day functioning. Good health allows people to optimize uptake of those nutrients through appetite, digestion and metabolism. Being free from disease also prevents nutrient losses such as with diarrhea which remains a top killer of children worldwide. Together diet and health jointly determine nutritional status.Below these are the underlying determinants of food access, care resources and health, water and sanitation services. These are determinants at the household or family level. Many of our interventions occur in this set of domains. (CLICK) Care resources are located in the middle and can be addressed by both sectors—nutrition awareness is an important care resource. 4. The underlying causes represent long routes, for longer-term and sustainable improvement. (CLICK) Interventions for both short and long-term exist in each sector. Both agriculture and health sectors can promote good nutrition (short routes) as well as address underlying problems (as highlighted in the long routes interventions).—this last line gets cut off, so presenter may wish to hand write it in the notes.5. Because of the multiple underlying causes of malnutrition, more than one sector is needed to solve population malnutrition problems. We need to let each sector contribute it’s part by doing what it does best. Agriculture and health are both necessary but neither is sufficient alone to solve the problem.
Examples of action areas not meant to be exhaustive
All countries in Blue are Radelet’s Emerging Countries (17) and Green are Threshold Countries. Among the Emerging Countries, only Burkina Faso worsened nutrition during the same period of Radelet’s Analysis (1996-2008) while no change for Mali, Mauritius, Lesotho and South AfricaSource:UNDP for Underweight prevalence monitored for the MDG: http://mdgs.un.org/unsd/mdg/Default.aspxUNICEF for Stunting and Underweight prevalence: State of the World’s Children http://www.unicef.org/sowc/Progress map for Africa taken from UNICEF and data for Underweight (Wt/Age) is from 1996-2004: http://www.unicef.org/progressforchildren/2006n4/files/PFC_MAP_ENG.pdfThe map illustrates that with economic growth the changes in stunting (an indicator or nutrition closely related to economic well being) has improved but only marginally.Change % stunting underweight (numbers are estimates and not adjustedBotswana -21 -5 Burkina Faso +8 -9Cape Verde (No Data)Ethiopia -17 -15Ghana -4 -9Lesotho -2 0Mali -6 +9Mauritius 0Mozambique -14 -7Namibia -2 -3Rwanda-3 -3São Tomé and Principe (No Data)Seychelles (No Data)South Africa 0 0Tanzania -9 -4Uganda -13 -4Zambia +5 -3 Changes in stunting and underweight prevalence from 1996 to 2008 was based on data from UNDP, UNICEF and WHO. The country list are all “Emerging Countries” based on an analysis by Radelet (2011) on economic, social and cultural data from Sub-Saharan countries. Radelet, Steven C., 2011 Emerging africa : how 17 countries are leading the way Center for Global Development, Washington DC http://www.cgdev.org/content/publications/detail/1424378/
Drivers of Undernutrition Bruce Cogill Ph.D. Bioversity International Nutrition and Marketing Diversity Programme Leader AIFSC Workshop“Food and nutrition in Eastern and Southern Africa” Nairobi, Kenya 10-11 September CGIAR Research Program on Agriculture for Nutrition and Health 1
Mean anthropometric z-scores using the WHO growth standard Wasting Underweight StuntingSource: Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R. Worldwide timing of growth faltering: revisiting implications for interventions usingthe World Health Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print) 3 3
Mean WAZ z scores by age using the new WHO standard, according to region (1–59 months) 4Source: Victora et al. Worldwide Timing of Growth Faltering: Revisiting Implications for Interventions. Figure 2. Pediatrics 2010;125
The conceptual framework of malnutritionPoor Dietary Quality 5
S Interventions Nutritional Status H O R- Breastfeeding T- Complementary feeding Food/nutrient R- Vitamin A Health O intake supplementation U T- Zinc E supplementation S- Hygiene Health, Food Household Care Care Water/- Agriculture Foodsecurity Access Resources Resources Sanitation L- Poverty reduction Services O- Income generation N- Education G- Health systems strengthening INSTITUTIONS R- Women’s O empowerment U POLITICAL & IDEOLOGICAL FRAMEWORK T E ECONOMIC STRUCTURE S RESOURCES ENVIRONMENT, TECHNOLOGY, PEOPLE Adapted from Ruel (2008) & UNICEF (1990) 6
What we do in Nutrition: Typical Interventions that should workImproving diet quality 1,000 days Nutrition serviceand diversity deliveryIron folate supplementation Promotion of breastfeeding (reduces Treatment of severe acute(reduces maternal deaths by 23%) mortality by 13%) malnutrition in facilities (reduces deaths by 55%)Maternal multiple micronutrients Social and behavior change for(reduces LBW infants by 16% and improved complementary feeding Zinc for management of diarrheareduces maternal anemia by 39%) (reduces stunting) (reduces mortality by 9%)Calcium supplementation (reduces Maternal supplements ofrisk of pre-eclampsia by 52%) energy, micronutrients, and proteinConditional cash transfers with (reduces LBW infants by 32%)nutrition education (reduces stunting) Deworming (reduces anemia andIron fortification and increases growth)supplementation (reduces anemia by Neonatal vitamin A (reduces infant28% and maternal mortality) mortality by 21% in South Asia)Dietary diversification (e.g. reduces Delayed cord clamping (reducesanemia and vitamin A deficiency) anemia)Vitamin A fortification orsupplementation (reduces childmortality by 23%)Universal salt iodization (improves IQ 7by 13 points)
Very useful as the conceptual framework is a causal model that mainly focuses on biological factors MORE COMPLEXIn East Africa additional dimensions enhancing undernutrition include:• Socio-Economical (poverty, inequities, behaviors…)• Environmental (sizeable proportion of land arid and semi- arid, prolonged droughts followed by floods exacerbated by climate change)• Political (conflicts, poor governance, rent seeking…) Governance• Behaviours 8
Comparing Under Five Nutrition with Changes in economic well being No Change in Wt/Age Ht/Age Burkina Faso, Mali, Mauriti us, Lesotho and South AfricaAll other countries inBlue had improvednutrition during sameperiod as growth rates Changes in Underweight in Blue countries was 1.3% per year (1996- 2008) to close to zero Growth analysis from Radelet (2011) CGDEV 9 Nutrition data for Underweight and Stunting for same period from UNICEF UNDP
Food Systems, Food Environments, EconutritionInterrelationships among nutrition, human health, agriculture andfood production, environmental health , and economic production 10
Underweight and obesity in women in 36 highest-stunting burden countries**Data on both underweight and obesity prevalence for adult women were available for 29 countries. Stunting based on infants andchildren under-five. Source: WHO Global Database on Body Mass Index (2010) http://apps.who.int/bmi/index.jsp11