Nutrition in food security assessments: The links 5 th - 9 th December 2011, Rome

Nutrition basics  Malnutrition?  An abnormal physiological condition causes by deficiencies, excesses or imbalanced of nutrients or energy.  Measurement of Malnutrition:  Anthropometry and Nutritional Status

Why is anthropometry important?  INDIVIDUALS Defines who has adequate nutrition and who is malnourished  POPULATIONS Determines prevalence of malnutrition in surveyed populations Anthropometry is the easiest way to measure nutritional status.

Why anthropometry in CFSVAs?  Primary goal: To link food security with nutritional outcomes, controlling for other influences (health/hygiene, caring practices)  Secondary goal: to provide indicative levels of key nutritional outcomes by zone, administrative boundary, or other grouping, as appropriate.  These goals must be clearly stated, agreed upon internally and with partners, and technically supported before the survey takes place!

Why anthropometry in CFSVAs? 2  The distinction between these two purposes has large implications on CFSVA design.  If nutrition is being collected only to relate to food security (primary goal), then tight sampling restrictions and other considerations are less.  If nutrition is being gathered to also provide prevalences by certain strata, then issues such as tight sampling restrictions will become more important  It is preferable, when possible, to satisfy both goals.

Occurs as a result of recent rapid weight loss or a failure to gain weight ACUTE MALNUTRITION Occurs as a result of inadequate nutrition over a long period of time CHRONIC MALNUTRITION WASTING (thinness) STUNTING (shortness) What are the two types of Growth Failure?

The building blocks of anthropometric indicators SexAge Height ( standing or lying) Weight MUAC 5 Oedema 6

Use of building blocks Weight Height/ length  acute malnutrition To assess if child is “wasted” or thin for his height  acute malnutrition  underweight To assess if child suffers from any type of protein-energy malnutrition  underweight Weight Age Height/ length Age  chronic malnutrition To assess if child is “stunted” or short for his age  chronic malnutrition MUAC or Oedema and

The key indicators of nutritional status 1 Weight-for-Height (WFH) reflects recent weight loss ACUTE MALNUTRITIONWASTING Height-for-Age (HFA) reflects skeletal growth CHRONIC MALNUTRITIONSTUNTING Weight-for-Age (WFA) is a composite index WASTING UNDERWEIGHT &/or STUNTING

MUAC: Mid Upper Arm Circumference WASTING THE RISK OF MORTALITY FROM ACUTE MALNUTRITION MUAC measurementClassification <115 mmSevere acute malnutrition 115 – 124 mmModerate acute malnutrition cmAt-risk of malnutrition > 135 mmNormal

Bilateral oedema (SAM) Marasmus Kwashiorkor

ABCDABCD A: Healthy B:Stunted C:Wasted D:Stunted & Wasted Who is stunted and who is wasted?

Source: SMART training modules

Hidden hunger Micronutrient deficiency  Iodine, vitamin A and iron deficiencies are the most important Their lack represents a major threat to the health and development, particularly children and pregnant women  Vitamin A deficiency (VAD)  Leading cause of preventable blindness in children  Increases the risk of disease and death from severe infections  An estimated to vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight

Example of hidden hunger Cordillera (n=884) Chuquisaca (n=477) Tarija (n=420) Acute malnutrition (12) 1,4% (0,8 - 2,4 95% C.I.) (4) 0,8% (0,3 - 2,3 95% C.I.) (3) 0,7% (0,2 - 2,3 95% C.I.) Underweight (52) 5,9% (4,2 - 8,1 95% C.I.) (12) 2,5% (1,2 – 5,4 95% C.I.) (15) 3,6% (2,1 - 6,1 95% C.I.) Chronic malnutrition (197) 22,3% (18,9-26,0 95% C.I.) (90) 18,8% (15,0-23,4 95% C.I.) (71) 16,9% (12,5 - 22,5 95% C.I.) ANAEMIA CordilleraChuquisacaTarija months 57,049,748, months 71,956,561,1

CALCULATING  

ENA for SMART

SMART plausibility check

ENA results

At which age do we see most wasting?  Wasting is more common amongst children during the weaning period.  Complementary foods are often inadequate.  Complementary foods are often not prepared in hygienic conditions which can result in diarrhoea.  Young children are susceptibles to other diseases.

ENA Report All n = 877 Boys n = 444 Girls n = 433 Prevalence of global malnutrition (<-2 z-score and/or oedema) (8) 0.9 % ( % C.I.) (6) 1.4 % ( % C.I.) (2) 0.5 % ( % C.I.) Prevalence of moderate malnutrition ( =-3 z-score, no oedema) (8) 0.9 % ( % C.I.) (6) 1.4 % ( % C.I.) (2) 0.5 % ( % C.I.) Prevalence of severe malnutrition (<-3 z-score and/or oedema) (0) 0.0 % ( % C.I.) (0) 0.0 % ( % C.I.) (0) 0.0 % ( % C.I.) Table 3.2: Prevalence of acute malnutrition based on weight-for- height z-scores (and/or oedema) and by sex Prevalence of oedema is 0.0 % Severe wasting (<-3 z-score) Moderate wasting (>= -3 and <-2 z-score ) Normal (> = -2 z score) Oedema Age (mo) Total no. No.% % % % Total Table 3.3: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema

Who is at risk of stunting?  Stunting occurs over a long period.  The poor quality of food is one of the factors in stunting.  Action is necessary in the formative years to prevent stunting.

Analysis and reporting  This example presents an external validation of the CFSVA nutritional findings against DHS findings.  This example is lacking 95% CI, which would allow a better comparison between the survey findings.

Analysis and reporting

Nutrition and food security  Assessments within WFP follow the conceptual framework: the nutritional status is an outcome of food security (and/or other factors).

WFP Conceptual Framework

Underlying causes of malnutrition Malnutrition Inadequate Food Intake Infection Household Food Security Social and Care Environment Access to Health Care & Healthy Environment Immediate Causes Underlying Causes Formal & Informal Infrastructure Political Ideology Resources Basic Causes

Nutrition in food security assessments  Improved food security and nutrition analysis should lead to more appropriate and targeted responses.  In assessments include core information on the factors influencing both food and nutrition security.  Non-food causes of nutrition insecurity are incorporated in assessments (poor health environment, inadequate care practices), but are less developed than food-related causes.

IMPORTANT !!!  Good quality data allows us to have good analysis. We cannot have good analyses from poor quality data.

Key crosstabulation - Descriptive Nutrition Strata  Sex of the child  Child age groups  Sex of the household head  Region/province  Livelihood groups  Ethnic group  Urban / rural  Total  Wasting (WHZ and or MUAC)  Stunting (HAZ)  Underweight (WAZ)

Under 5 nutrition by ethnic group- Laos

Key crosstabulation – analysis Nutrition Food security / access  Wasting (WHZ and or MUAC)  Stunting (HAZ)  Underweight (WAZ)  Economic vulnerability  Expenditure / income  Share food expenditure  CSI  Diet quality  FCS  FC groups  Diet diversity  Food energy from staples  Diet quantity  Kcal

Key crosstabulation – analysis Nutrition Other household critical indicators  Wasting (WHZ and or MUAC)  Stunting (HAZ)  Underweight (WAZ)  Improved source of water  Improved sanitation  Crowding index  Household size  Percentage of dependents  Asset /wealth index  Household has chronically sick member  Etc…

Key crosstabulation – analysis Nutrition Mothers  Health status  Antenatal cares  Age of the mother?  Education  Number of kids  Wasting (WHZ and or MUAC)  Stunting (HAZ)  Underweight (WAZ)

Key crosstabulation – analysis Nutrition Health – child care  Health care access  Hand washing  Breastfeeding practices  Complementary feeding practices  Child diet diversity score (IDDS)  Child food consumption score?  Immunizations  Prevention (mosquito net)  Wasting (WHZ and or MUAC)  Stunting (HAZ)  Underweight (WAZ)

Reporting  For anthropometry  Prevalence %  Number of measured children  CI  For FS analysis  Correlations levels and/or if the relation is significant  Level of Sig. (<0.05 or 0.01)

Incorporating nutrition into food security analysis  Relating food security to nutritional outcomes.  Nutrition can be analyzed as an outcome of food consumption/security (nutritional status as the dependant variable) CAUSAL (two-way or multi-way) ANALYSIS  Nutrition can be a descriptive variable of food consumption/security DESCRIPTIVE (one-way) ANALYSIS  Nutrition can be viewed as a component of food security (utilization) NUTRITIONAL STATUS + X = FOOD SECURITY

Incorporating nutrition into food security analysis (or.. food security into nutrition analysis)  There are several methodologies for making the link between food security and nutritional outcomes. This depends on the approach to food security taken (remember the analytical frameworks).  Descriptive analysis (one way analysis)  Food security = nutrition security (depending on interpretation)  Causal/relational analysis (descriptive analysis, plus two-way or multivariate analysis, examples following)  Is food consumption/household food security an underlying cause of nutritional status, or are other factors at play?

Two-way analysis  Starting to make statements of association

Multi-way analysis  … and linking food security and nutrition

Case study - Liberia  Areas found to have high food insecurity (by several methodologies) do not have the highest prevalences of stunting, wasting, underweight.  How is this reconciled?

Liberia (nutritional outcomes)

Liberia (food security)

From the regression analysis  The analysis revealed:  Food consumption is not associated with wasting.  Food access is not associated with wasting.  Wasting is primarily associated with perceived birth size, caring practices (age of introduction of solid foods), and episodes of diarrhea  Female children and older children are significantly less wasted than male children and younger children  MCH food assistance played a role in improving nutritional status of children  Continued breastfeeding in addition to intake of cereals and liquids as revealed by 24-hour recall had better impact on the nutritional status of young children  Children who were introduced to solid foods especially before the age of four months were more wasted than other age groups

Example question:  In Swaziland, is there a difference in nutritional status depending on socio economic status, estimated by assets (asset poor/not asset poor), independent of education attainment?

Example from Swaziland From Swaziland data. Education of mother, asset poor/not asset poor

Regression Analysis  We could also do a regression analysis to explore the statistical significance of this same question.

Regression Analysis

Example question two:  In Swaziland, is stunting status related to the age of the child, independent of sex of child?  Is stunting status related to the sex of child, independent of age?

Stunting by age group and sex: Swaziland

Swaziland  Are the trends presented in the previous graph statistically significant?  Controlling for age group, are boys more stunted than girls?  Does age group have a significant relationship with stunting?

Food consumption and underweight

Food consumption and stunting

Rates of GAM by FS Group

Rates of GCM by FS group

TotalNAMAM NMeanSDNMeanSDNMeanSD FCS dry season p<0.069 FCS rainy season p<0.028 Means comparison. FCS and malnutrition (Sierra Leone) Seasonality

Case study – Burundi – unexpected results 1? FCS Wasting WHZ Poor7.9% Borderline10.3% Acceptable7.9%

72.7% 1.0% 0.9% 4.9% 1.4% 18.1% FSC Poor 43.3% 3.6% 8.6% 9.3% 3.6% 28.5% 3.1% FSC Border line 25.8% 8.9% 7.7% 22.1% 7.5% 0.7% 21.4% 5.9% FSC Adequate

Malnutrition and food groups consumption NAM = -1 SD < WHZ < 1SD AM = WHZ < -2SD

Malnutrition and food groups consumption by age

Food consumption and sickness

Comparison among geographic units

Comparison among geographic units 2

Key nutrition terms in French English Acute Malnutrition/wasting Chronic malnutrition/stunting Underweight MUAC Body Mass Index (BMI) Anthropometric thresholds Global, moderate, severe French Malnutrition Aiguë/Emaciation Malnutrition chronique/ Retard de croissance Insuffissance pondérale Périmètre brachial (PB) Indice de masse corporel (IMC) Seuils anthropométriques Globale, moderée, sévère