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Post2015 Nutrition Consultation Session4 Kay Dewey


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Post2015 Nutrition Consultation Session4 Kay Dewey

  1. 1. Candidate indicators for measuring progress at improving nutrition Kathryn G. Dewey, PhD Program in Community and International Nutrition University of California, Davis February 20, 2013
  2. 2. Anthropometric indicators (children)• Stunting: HAZ < -2 – Reflects long-term linear growth, both prenatal and postnatal – Moderately sensitive to nutrition interventions – % stunted increases with age until ~24 mo, so indicator should be measured on children 24+ mo (or age-adjusted, if includes 0-24 mo?)• Wasting: WHZ < -2 – Reflects acute undernutrition – Sensitive (in short-term) to nutrition interventions, but recidivism is common• Underweight: WAZ < -2 – Reflects combination of stunting and wasting, so is not as informative – Rates decrease as overweight becomes more common, even if stunting not reduced• Overweight: WHZ > +2 – Good indicator of rising rates of child obesity
  3. 3.  Stunting is a non-specific indicator of nutritionalstatus and overall health, including:- Quantity and quality of dietary intake (mother & child)- Pre- and post-natal exposure to infections- Environmental insults (e.g. mycotoxins, household airpollution)- Caregiving Stunting is linked to numerous adverse outcomes:• Increased child mortality• Delayed development and less schooling• Lower wages in adulthood• Increased obstetrical risks (women)
  4. 4. How strong is the link between stunting and child development/schooling?• Attained schooling +0.5 y per 1 Z difference in HAZ at 2 y of age in Brazil, Guatemala, India, Philippines (Victora et al. 2008)• Higher cognitive scores at 5 years among Vietnamese children who were taller at 1 y (+0.20-0.25 SD per 1 Z difference in HAZ) (Young Lives Project 2009)• Jamaican children stunted at 9-24 mo had cognitive deficits that persisted at 17-18 y (Walker et al. 2005)• Difference of 4 points in MDI at 18 mo between stunted vs. non- stunted children in Tanzania (McDonald et al. 2013) Heterogeneity in the strength of the association with stunting Timing of stunting may play a role (e.g. pre- vs. postnatal)
  5. 5. Dietary candidate indicators• Children under two: IYCF indicators• Adults – Household food insecurity – Measures of consumption (energy intake?) – Dietary diversity among women of reproductive age
  6. 6. Recommended core IYCF indicators• Breastfeeding: a) Early initiation of breastfeeding; b) Exclusive breastfeeding under 6 months; c) Continued breastfeeding at 1 year• Introduction of solid, semi-solid or soft foods• Minimum dietary diversity: Proportion of children 6-23 mo who receive foods from 4 or more food groups (out of 7): a) grains, roots, tubers, b) legumes, nuts, c) dairy, d) flesh foods, e) eggs, f) vitamin A-rich fruits & vegs, g) other fruits & vegs• Minimum meal frequency: Proportion of breastfed and non-breastfed children 6-23 mo who receive solid, semi-solid, or soft foods (including milk feeds for non-breastfed children) the minimum number of times or more (BF: 2 times at 6-8 mo, 3 times at 9-23 mo; non-BF: 4 times 6-23 mo)• Minimum acceptable diet: Proportion of children 6-23 mo who receive a minimum acceptable diet – Breastfed children who had at least minimum dietary diversity and minimum meal frequency – Non-breastfed children who received at least 2 milk feedings and had minimum dietary diversity and minimum meal frequency• Consumption of iron-rich or iron-fortified foods
  7. 7. Median prevalence values of IYCF indicators for 46 countries (data range from 2002 to 2008) Lutter C K et al. Pediatrics 2011;128:e1418-e1427©2011 by American Academy of Pediatrics
  8. 8. Women’s dietary diversity & micronutrient adequacy(Arimond et al., Women’s Dietary Diversity Project, J Nutr. 2010) “MPA” is probability of adequacy averages across 11 micronutrients
  9. 9. Dietary diversity as an indicator?• Reflects dietary quality• All food-based national dietary guidelines include this dimension, usually via recommended food groups for daily consumption• DD indicators are robust: Across all studies and all DD indicators, there are moderate to strong associations with nutrient density and/or nutrient intakes• However, DD indicators are imperfect: Indicator performance (sensitivity, specificity, and best cut-offs) vary by context and all indicators result in some misclassification• For children 6-23 mo, “minimum acceptable diet” may be a better indicator because it can be used for comparisons across time and between populations with different rates of continued breastfeeding.
  10. 10. Summary - Anthropometric• Consider stunting as key indicator rather than underweight? • Pros: better indicator of conditions that support health and development; if weight is measured can also track overweight • Con: requires measuring height – technical & resource challenges• Also include adult & child overweight as indicators?
  11. 11. Summary - Dietary• Children (6-24 mo): consider minimum acceptable diet as key indicator? – Pros: raises attention to IYCF, dietary quality; lots of room for improvement – Cons: composite indicator requires several survey questions; validation results better for dietary diversity than for meal frequency• Adults: consider two indicators? – Household food insecurity • Pros: marker of access to food; sensitive to economic trends • Cons: requires several survey questions; are cross- population comparisons valid? – Dietary diversity among women of reproductive age • Pros: reflective of dietary quality; validation data available • Cons: sensitivity, specificity and best cut-off values vary across populations