Food & Nutrition Situation     in Bangladesh           Dr Tahmeed Ahmed           Director           Centre for Nutrition ...
Intergenerational Cycle of Malnutrition                            Higher                           mortality       Impair...
Different Types of Childhood Malnutrition                                                             Normal height for ag...
Stunting in Early Childhood & Later      Development Outcomes               Philippines, n=248958      Not stunted56      ...
UNICEF; Black R, 2008
Trends in Prevalence of Underweight in   Under-5 Children in Bangladesh                         80 Percentage below -2SD N...
Trends in Prevalence of Underweight in   Under-5 Children in Bangladesh                         80 Percentage below -2SD N...
Trends in Prevalence of Underweight in   Under-5 Children in Bangladesh                         80 Percentage below -2SD N...
Trends in Prevalence of Underweight in   Under-5 Children in Bangladesh                         80 Percentage below -2SD N...
Trends in Prevalence of Underweight in   Under-5 Children in Bangladesh                         80 Percentage below -2SD N...
Percentage below -2SDB                                NCHS/WHO Reference an   gl      ad                                 1...
Trends of BMI of Women in Bangladesh                                  60Percent of women with BMI <18.5                   ...
On the Causes of Malnutrition       Population increases in a       geometric ratio, while the means       of subsistence ...
Limited Land Mass with the Highest        Population Density                                1200                          ...
Korail Slum
•Close to 27% or 40 million live in urbanareas •About 40% of Dhaka city population lives in slums •Dhaka is the fastest gr...
On the Causes of Malnutrition               Famine and malnutrition               are a result of a collapse              ...
•Poverty•Food insecurity•Poor maternal nutrition•Low birth weight•Low rates of EBF•Lack of proper CF•Frequent illnessesBBS...
Food Security in Urban SlumsHousehold       Dhaka   Chittagong Khulna Rajshahi Allconsumption<2,122           42.4      56...
Share of Energy Intake in Bangladesh                          Staples                          Non-staple                 ...
Slum   Non-slumUnderweight (BMI <18.5)   26.7   12.9Over weight (BMI ≥25)     14.8   34.2Diabetes mellitus         5.5    ...
Severe Acute Malnutrition2.9% in Bangladesh~500,000 childrenAt risk of death from•   Hypoglycemia•   Hypothermia•   Infect...
Admission             2 weeks                                A 2 yr old girl with                                dysentery...
Timeliness: Early Versus Late        Presentation
There has been some improvement    but much more is required
The Lancet Series on Maternaland Child Undernutrition
Evidence-Based Interventions             Bhutta ZA, Ahmed T et al. Lancet 2008
Interventions with Sufficient Evidence to          Implement in All CountriesMaternal and Birth          Newborn Babies   ...
Interventions with Sufficient Evidence to          Implement in All CountriesMaternal and Birth          Newborn Babies   ...
Evidence-Based Interventions             Bhutta ZA, Ahmed T et al. Lancet 2008
Coverage is most important !                Reduction    Reduction          % of                in deaths    in stunting  ...
To eliminate stunting in the longer term, theseInterventions should be supplemented by improvementsin the underlying deter...
Recommendations• Business as usual will not work• Need to think out of the box now• There is no one size that fits all, se...
Recommendations• Immediate need is to improve existing services  and scale them up  – Primary health care focusing on chil...
Recommendations• Primary health care intervention package should  be expanded and improved  – IFA tablets for adolescent g...
Undernutrition hotspots need special attention– Monga-prone areas in the north– The coastal belt and char areas– Areas in ...
Recommendations• But the ultimate goal is to prevent/control rapid  unplanned urbanization  – Create livelihoods in rural ...
Ahmed 5 introduction to key indicators
Ahmed 5 introduction to key indicators
Ahmed 5 introduction to key indicators
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Ahmed 5 introduction to key indicators

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  • For paper 3, the authors reviewed 45 interventions, including breastfeeding promotion, complementary feeding promotion strategies with or without provision of food supplements, micronutrient interventions, and general supportive strategies for improving family and community nutrition and disease burden reduction. This table summarizes the various interventions with demonstrated impact on maternal and child undernutrition. Importantly, for each of the conditions contributing to nutrition-related disability and death there are already highly effective interventions available.
  • Explain that figure shows the sort of information generated by the model. Go through what it shows – what happens to children between birth and 36 months of age – so by 36 months of age about 9% of children have died and of those who survive over half (58%) are stunted.
  • Explain that figure shows the sort of information generated by the model. Go through what it shows – what happens to children between birth and 36 months of age – so by 36 months of age about 9% of children have died and of those who survive over half (58%) are stunted.
  • Ahmed 5 introduction to key indicators

    1. 1. 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
    2. 2. Intergenerational Cycle of Malnutrition Higher mortality Impaired rate mental development Baby Low Birth Untimely / inadequate Weight weaning Frequent infections Inadequate Foetal food, health Malnutrition & care Child Malnourished Stunted Reduced ADULTS mental Pregnancy capacity Low Weight Gain Adolescent Stunted Higher Reduced maternal mental mortality capacity Llanos, Alvear, Uauy 2004
    3. 3. Different Types of Childhood Malnutrition Normal height for ageChildren Wasted Stunted Underweight Normal Low weight for height Low height for age Low weight for age
    4. 4. Stunting in Early Childhood & Later Development Outcomes Philippines, n=248958 Not stunted56 Mildly stunted54 Moderately/severely52 stunted504846 Cognitive score at 8 y Mendez MA, 1999
    5. 5. UNICEF; Black R, 2008
    6. 6. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 Percentage below -2SD NCHS/WHO Reference 70 60 50 40 30 20 10 90 00 4 07 19 7 00 20 99 0 9- -2 2 1 98 99 6- 1 19 9 19 Ahmed T et al. In press.
    7. 7. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 Percentage below -2SD NCHS/WHO Reference 70 60 50 40 30 20Reasons for the decline: 10Increased literacy Fertility rate reducedMeasles vaccination now at 83% Family size smaller 90 00 07 19 04 electrification 7Vitamin A supplementation coverage at 88% Rural 20 99 0 9- -2 20 1 98 99 6-Increased food1production & energy intake Microcredit? 19 9 19 Ahmed T et al. In press.
    8. 8. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 Percentage below -2SD NCHS/WHO Reference 70 60 50 40 30 20 10 90 00 4 07 19 7 00 20 99 0 9- -2 2 1 98 99 6- 1 19 9 19 Ahmed T et al. In press.
    9. 9. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 Percentage below -2SD NCHS/WHO Reference 70 60 50 40 30 20Assumptions on reasons for the stagnation: 10•Increase in inequity (increase in Gini coefficient)•Reduction in infant mortality rate resulting in more infants surviving but 90 00 07with malnutrition -19 04 7 20 99 9 20 20 9- 1 98 6- 1 99 9 1 19 Ahmed T et al. In press.
    10. 10. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 Percentage below -2SD NCHS/WHO Reference 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 90 00 4 07 15 19 7 00 20 20 99 0 9- -2 2 1 98 99 6- 1 19 9 19 Ahmed T et al. In press.
    11. 11. Percentage below -2SDB NCHS/WHO Reference an gl ad 10 20 30 40 50 60 0 e sh 20 07 In 47.0 di a 20 05 -0 6 47.8 N ep al 20 C 0 6 am 44.9 bo di a 20 05 35.6 Et hi op ia 20 0 5 R 38.5 w an da 20 05 U 22.6 ga than in Sub-Saharan Africa nd a 20 06 20.2 Malnutrition is more common in Asia
    12. 12. Trends of BMI of Women in Bangladesh 60Percent of women with BMI <18.5 52.0 50 45.4 40 34.3 29.7 30 20 10 0 1996-97 1999-2000 2004 2007
    13. 13. 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)
    14. 14. Limited Land Mass with the Highest Population Density 1200 Bangladesh Population density inPopulation Density (/ sq.km.) 1000 Bangladesh is 3 to 40 800 times higher than other ‘mega’ countries 600 Japan 400 Pakistan India Indonesia 200 USA China 0 Nigeria 0 200 400 600 800 1000 1200 1400 Mexico Russia Brazil Population (millions)
    15. 15. Korail Slum
    16. 16. •Close to 27% or 40 million live in urbanareas •About 40% of Dhaka city population lives in slums •Dhaka is the fastest growing city Korail Slum
    17. 17. 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
    18. 18. •Poverty•Food insecurity•Poor maternal nutrition•Low birth weight•Low rates of EBF•Lack of proper CF•Frequent illnessesBBS, World Bank, WFP 2005
    19. 19. Food Security in Urban SlumsHousehold Dhaka Chittagong Khulna Rajshahi Allconsumption<2,122 42.4 56.0 52.0 61.3 47.8kcal/person/d<1,805 24.2 35.8 38.5 36.0 29.0kcal/person/d Urban food security Atlas, 2008
    20. 20. Share of Energy Intake in Bangladesh Staples Non-staple plants Fish and animal Howarth Bouis, 2006
    21. 21. Slum Non-slumUnderweight (BMI <18.5) 26.7 12.9Over weight (BMI ≥25) 14.8 34.2Diabetes mellitus 5.5 17.0Hypertension 12.1 21.4- Carbohydrates in diet- ‘Fast food’ culture- Lack of exercise
    22. 22. Severe Acute Malnutrition2.9% in Bangladesh~500,000 childrenAt risk of death from• Hypoglycemia• Hypothermia• Infections
    23. 23. Admission 2 weeks A 2 yr old girl with dysentery, pneumonia Weighed only 3.8 kg Treated with • therapeutic diets • antibiotics 4 weeks • micronutrients 5 weeks Diagnosed TB and treated appropriately
    24. 24. Timeliness: Early Versus Late Presentation
    25. 25. There has been some improvement but much more is required
    26. 26. The Lancet Series on Maternaland Child Undernutrition
    27. 27. Evidence-Based Interventions Bhutta ZA, Ahmed T et al. Lancet 2008
    28. 28. Interventions with Sufficient Evidence to Implement in All CountriesMaternal and Birth Newborn Babies Infants and ChildrenOutcomes • Promotion of • Promotion of• Iron folate breastfeeding (individual breastfeeding (individualsupplementation and group counseling) and group counseling)• Maternal supplements of • Behavior changemultiple micronutrients communication for improved• Maternal iodine through complementary feeding • Zinc supplementationiodization of salt • Zinc in management of• Maternal calcium diarrheasupplementation • Vitamin A fortification or• Interventions to reduce supplementationtobacco consumption or • Universal salt iodizationindoor air pollution • Handwashing or hygiene interventions •Treatment of SAM Bhutta ZA, Ahmed T et al. Lancet 2008
    29. 29. Interventions with Sufficient Evidence to Implement in All CountriesMaternal and Birth Newborn Babies Infants and ChildrenOutcomes • Promotion of • Promotion of• Iron folate breastfeeding (individual breastfeeding (individualsupplementation and group counseling) and group counseling)• Maternal supplements of • Behavior changemultiple micronutrients communication for improved• Maternal iodine through complementary feeding • Zinc supplementationiodization of salt • Zinc in management of Hygiene interventions:• Maternal calcium diarrheasupplementation • Vitamin A• Interventions Reduce incidence of diarrhea to reduce by 30%, fortification or supplementationtobacco consumption or reduce odds of stuntingindoor air pollution • Universal salt iodization • Handwashing or hygiene interventions •Treatment of SAM Bhutta ZA, Ahmed T et al. Lancet 2008
    30. 30. Evidence-Based Interventions Bhutta ZA, Ahmed T et al. Lancet 2008
    31. 31. Coverage is most important ! Reduction Reduction % of in deaths in stunting DALYs averted99% coverage 25% 35% 25%90 % coverage 22% 32% 23%70 % coverage 17% 27% 17% Bhutta ZA, Ahmed T et al. Lancet 2008
    32. 32. To eliminate stunting in the longer term, theseInterventions should be supplemented by improvementsin the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women’s empowerment.
    33. 33. 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
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. 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

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