1) Malnutrition in Bangladesh persists due to an intergenerational cycle where malnourished adults have malnourished children who grow up to be malnourished parents. 2) While underweight prevalence among children under 5 has declined significantly from over 70% in 1990 to 41.3% in 2014 due to factors like increased literacy, vaccination programs, and food production, the rate of decline has stagnated in recent years. 3) Continued high levels of malnutrition threaten Bangladesh's development, with stunted children experiencing impaired mental and physical development that can persist into adulthood.

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

3. 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

4. Different Types of Childhood Malnutrition
Normal height for age
Children
Wasted Stunted Underweight
Normal
Low weight for height Low height for age Low weight for age

5. Stunting in Early Childhood & Later
Development Outcomes
Philippines, n=2489
58 Not stunted
56 Mildly stunted
54
Moderately/severely
52 stunted
50
48
46
Cognitive score at 8 y
Mendez MA, 1999

6. UNICEF; Black R, 2008

7. 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.

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
Reasons for the decline:
10
Increased literacy Fertility rate reduced
Measles vaccination now at 83% Family size smaller
90 00 07
19 04 electrification
7
Vitamin 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.

9. 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.

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
Assumptions 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 07
with malnutrition -19 04
7
20
99
9 20 20
9-
1
98
6-
1 99
9
1
19
Ahmed T et al. In press.

11. 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.

12. Percentage below -2SD
B 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

13. Trends of BMI of Women in Bangladesh
60
Percent 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

14. 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)

15. Limited Land Mass with the Highest
Population Density
1200
Bangladesh Population density in
Population 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)

16. Korail Slum

17. •Close to 27% or 40 million live in urban
areas
•About 40% of Dhaka city population lives
in slums
•Dhaka is the fastest growing city
Korail Slum

18. 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

19. •Poverty
•Food insecurity
•Poor maternal nutrition
•Low birth weight
•Low rates of EBF
•Lack of proper CF
•Frequent illnesses
BBS, World Bank, WFP 2005

20. Food Security in Urban Slums
Household Dhaka Chittagong Khulna Rajshahi All
consumption
<2,122 42.4 56.0 52.0 61.3 47.8
kcal/person/d
<1,805 24.2 35.8 38.5 36.0 29.0
kcal/person/d
Urban food security Atlas, 2008

21. Share of Energy Intake in Bangladesh
Staples
Non-staple
plants
Fish and
animal
Howarth Bouis, 2006

22. Slum Non-slum
Underweight (BMI <18.5) 26.7 12.9
Over weight (BMI ≥25) 14.8 34.2
Diabetes mellitus 5.5 17.0
Hypertension 12.1 21.4
- Carbohydrates in diet
- ‘Fast food’ culture
- Lack of exercise

23. Severe Acute Malnutrition
2.9% in Bangladesh
~500,000 children
At risk of death from
• Hypoglycemia
• Hypothermia
• Infections

25. 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

26. Timeliness: Early Versus Late
Presentation

28. There has been some improvement
but much more is required

29. The Lancet Series on Maternal
and Child Undernutrition

30. Evidence-Based Interventions
Bhutta ZA, Ahmed T et al. Lancet 2008

31. Interventions with Sufficient Evidence to
Implement in All Countries
Maternal and Birth Newborn Babies Infants and Children
Outcomes • Promotion of
• Promotion of
• Iron folate breastfeeding (individual breastfeeding (individual
supplementation and group counseling) and group counseling)
• Maternal supplements of • Behavior change
multiple micronutrients communication for improved
• Maternal iodine through complementary feeding
• Zinc supplementation
iodization of salt
• Zinc in management of
• Maternal calcium
diarrhea
supplementation
• Vitamin A fortification or
• Interventions to reduce
supplementation
tobacco consumption or
• Universal salt iodization
indoor air pollution
• Handwashing or hygiene
interventions
•Treatment of SAM
Bhutta ZA, Ahmed T et al. Lancet 2008

32. Interventions with Sufficient Evidence to
Implement in All Countries
Maternal and Birth Newborn Babies Infants and Children
Outcomes • Promotion of
• Promotion of
• Iron folate breastfeeding (individual breastfeeding (individual
supplementation and group counseling) and group counseling)
• Maternal supplements of • Behavior change
multiple micronutrients communication for improved
• Maternal iodine through complementary feeding
• Zinc supplementation
iodization of salt
• Zinc in management of
Hygiene interventions:
• Maternal calcium
diarrhea
supplementation
• Vitamin A
• Interventions Reduce incidence of diarrhea
to reduce by 30%, fortification or
supplementation
tobacco consumption or
reduce odds of stunting
indoor air pollution
• Universal salt iodization
• Handwashing or hygiene
interventions
•Treatment of SAM
Bhutta ZA, Ahmed T et al. Lancet 2008

33. Evidence-Based Interventions
Bhutta ZA, Ahmed T et al. Lancet 2008

34. Coverage is most important !
Reduction Reduction % of
in deaths in stunting DALYs
averted
99% coverage 25% 35% 25%
90 % coverage 22% 32% 23%
70 % coverage 17% 27% 17%
Bhutta ZA, Ahmed T et al. Lancet 2008

35. To eliminate stunting in the longer term, these
Interventions should be supplemented by improvements
in the underlying determinants of undernutrition, such as
poverty, poor education, disease burden, and lack of
women’s empowerment.

36. 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

37. 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

38. 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

39. 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

40. 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