Assessment of Nutritional Status Food Security and Nutritional Indicators for Needs Assessment – Collating Information Firdousi Naher International Food Policy Research Institute Training Course on: Assessment of Nutritional Status 18-22 December 2011 Dhaka

Four decades of remarkable growth Poverty declined from 75% in 1971 to 31.5% in 2010 Between 2005-2010 GDP per capita grew at 6.19% Appreciable reduction in non-income welfare indicators: population growth rates have halved lowered infant and child mortality expanded immunisation coverage improved water and sanitation augmented life expectancy increased net primary enrolment ratio eliminated gender gap in schooling #Currently GDP per capita is almost USD 700 compared to USD123 in 1971 #population growth rates have halved [2.63 (1971) to 1.38 (2009)] lowered infant mortality (145 in 1970s to 38 in 2011) and child mortality reduced by 70% expanded immunisation coverage (more than 90%) improved water and sanitation [94%-98%(1994-2006) and 39%-54% (1990-2009)] augmented life expectancy (from 45 years to 64 years) increased net primary enrolment ration (72.5%-108% (1990-2009) eliminated gender gap in schooling [48%-69% (1990-2005)] better disaster preparedness Page 2

Similar developments in the food economy Dramatic increase in rice production leading to closing the gap between rice availability and rice requirement In the past decade, 84% of the increase in production has been brought about through increased yield; 16% through area expansion Broadened consumption basket In the early 1970s, Bangladesh was a seriously food deficit country with a population of about 75 million Today, the population is over 150 million and the country is in the brink of self-sufficiency in rice production Rice production has tripled since the early 1970s Page 3

Trends in maternal and child under-nutrition Page 4

Slow spread of these developments into nutrition Page 5

Why has nutrition eluded the progress in food, agriculture and health? Certain expectations of policy makers often leave nutrition out of lead policy Stagnated consumption patterns Achieving food security through focus on both input and output market have not always complemented each other Need for strong of institutional arrangements for coordination Need for greater priority in nutrition initiatives Need to strengthen development administration Need for more gender sensitive policies aimed at greater empowerment of women Greater awareness needed on dietary diversity For e.g. within the agriculture sector, the popular notion is “food security will translate to nutrition security”. Thus exists a general aversion to allocate greater resources to nutrition For instance, since nutrition falls under the purview of the Ministry of Health, its share in budgetary allocations is often sidelined as a part of public health lack of professional capacity in the nutrition and agriculture sectors Common perception is that agrisector is low pdty sector so this sect yields poor returns. Thus devoting additional resources to other sectors such as health, education and infrastructure would be more meaningful. Real rice price has fallen 38% from 1983 -2007 primarily due to R&D and technological progress in rice cultivation. But the price of non-staples rich in nutrients have risen sharply Currently the pulses-rice price ratio is almost 3 while the oils-rice price ratio 4.5 and fish-rice price ratio is 9 For the poor, such trends in prices have pushed the consumption of non-staples very low. Has helped the rural landless and urban poor the level of technology and institutional innovations that made this price decline possible must be maintained. Innovation dist channel, homestead gardening, transport, road network, ngos and cooperatives etc. The government has sought to achieve food self-sufficiency in the country through interventions in the output market as well as the input market. Ministry of Food stresses on the output market - equitable distribution of food through government procurement and distribution Ministry of Agriculture, on the other hand, has stressed on augmenting total production of rice through increased adoption of the green revolution technology. This dual pursuance has not always complemented each other and has sometimes offset the effect of one on the other. In fact, the National Food and Nutrition Policy of the MOHFW explicitly calls for its effective implementation through the co-ordinated efforts of four different sectors viz. (i) food, agriculture, fisheries, livestock and forestry (ii) health, family welfare and environment (iii) nutrition education and communication and (iv) community development and social welfare. It is very important to have some mechanism for effective co-ordination among such a large troupe. However, in the government mechanism in Bangladesh, there are very few institutional arrangements for co-ordination. The three notable ones are the Food Planning and Monitoring Unit (FPMU) under the Ministry of Food, Economic Relations Division (ERD) under the Ministry of Finance and the Bangladesh National Nutrition Council (BNNC). There is an ardent need to look into how these institutional arrangements can be changed and developed and new ones brought to the fore. Ministry of Health & Family Welfare Ministry of Agriculture Ministry of Food and Disaster Management Ministry of Women and Children Affairs Ministry of Planning Ministry of Finance Ministry of Education (school feeding program) Ministry of Irrigation and Water Management Ministry of Local government and Rural Development Ministry of Environment and Forests Ministry of Information Comprehensive coverage has meant that activities are not always prioritised For instance, the first comprehensive public nutrition program – BINP- yielded disappointing child nutritional outcomes despite high levels of participation in project activities. Reasons for this include of neglect of key decision makers in nutritional choices, the focus on pregnancy weight gain rather than pre-pregnancy nutritional status, supplementary feeding often got shared or substituted for regular meals Unsystematic and isolated nutritional programs directed at specific micronutrient problems such as iodine, vitamin A or iron. Absence of strong, elected local government structures make effective implementation of policies difficult No clear demarcation of roles often lead to conflicts at local level between MPs and local government leaders Critical manpower and resources needed for initiating action is lacking Disparate initiatives by differing governments in Bangladesh have also tended to thwart progress in many fields Lack of institutions in efficient service delivery –outdated and/or inadequate medicines, vaccination, ‘ghost doctors’ at rural level Cautious government attitude towards NGOs Need for a clear demarcation of roles Need for a sound legal framework Page 6

3 Types of Food and Nutrition Insecurity First, there are those chronically food-insecure – about 28 million Bangladeshis – who cannot purchase enough rice or wheat to meet energy requirements. Second, those who normally meet energy requirements, but run the very real risk of loosing access to food – due to shocks – are also food insecure. Third, a large percentage of the population is food-insecure due to diet quality rather than diet quantity. Page 7

What is nutritional assessment? Measurements of body size, body composition or body function to diagnose nutrient deficiency or deficiencies Measures derived from nutritional assessments may be viewed as biological manifestation of nutrition security Page 8

Why is nutritional assessment important? Helps identify geographic locations most in need of development projects Useful input into project formulation through needs assessment For monitoring and evaluation of projects since human welfare impact of the project can be directly measured through nutritional assessment Page 9

Nutritional indicators for needs assessment Anthropometric indicators Application Proportion of children with haz<-2 Proportion of children with whz<-2 Proportion of adolescents and adults with low (high) Body Mass Index (BMI) Prevalence of low mid-upper arm circumference (MUAC) in children, 6 - 59 months Prevalence of stunting Prevalence of wasting Prevalence of thinness (obesity) Protein-energy malnutrition, low muscle mass, risk of death Laboratory indicators 6. Prevalence of low serum retinol in preschool children 7. Prevalence of low hemoglobin in preschool or school-age children 8. Prevalence of low hemoglobin in non-lactating, non-pregnant women 9. Prevalence of low hemoglobin in men Vitamin A deficiency Prevalence of anemia Underweight Page 10

Different sources of data on nutrition Bangladesh National Nutrition Survey 1962-64, 1975-76, 1981-82, 1995-96 Done by the Institute of Nutrition and Food Science (INFS) under the University of Dhaka Demographic and Health Survey 1993-94, 1996-97, 1999-2000, 2004, 2007 Done by the National Institute of Population Research and Training (NIPORT) under the MoHFW Child Nutrition Survey 1985-86, 1989-90, 1992, 1995-96, 2000, 2005 Done by the Bangladesh Bureau of Statistics (BBS) Any needs assessment should start with collating nutritional data from as many different pop-based sources as possible. The information should be arranged by indicator, age group studied and year of collection. Page 11

Nutrition data sources ………………..cont’d Food Security and Nutritional Surveillance Project (FSNSP) 2010 in 3 rounds so as to provide seasonal data on maternal care and malnutrition and child care and malnutrition Done by Helen Keller International (HKI) in collaboration with BRAC University and BBS National Nutrition Program (Baseline Survey) 2004 Done by ICDDR,B in collaboration with NIPORT and IPHN FSNSP 23000hh and 26000 children Page 12

CNS and BDHS Child Nutrition Survey Demographic and Health Survey Nationally representative. Same households as HIES but with at least one child, < 60 months available Collects data on nutritional status of children 0-59 months by age, gender, location, season, region etc. Prior to 2005, sample included children 6-71 months. Nutrition status can be related to different indicators of household food security From 2005, the CNS is re-named as Mother and Child Nutrition Survey Nationally representative. DHS 2004 and 2007 used the 2001 Population Census as the sampling frame. Focus is on demographics -fertility, use of family planning methods, infant and child mortality, maternal and child health, HIV/AIDS. On the nutrition front, it collects data on infant feeding and nutritional status of women and children. Sample includes children < 60 months, women 10-49 years and men 15-54 years. Prev BDHS included ever married women and currently married men. Now incl, never married women and formerly married men also. Page 13

Child nutrition 1995-96: comparing different data sources INFS age group:6-71 months, 1447 hhs in 41 locations (32 R+9U), jul95-may96 BBS age group:6-71 mos, 2614 children (1800R+814U)frm 1910 hh in 200 locatn (138+62), data frm Oct95-aug96 DHS age group: 0-59months, 9127 ever married women (10-49), 3312 curr married men (15-59), 6230 kids <5y, nov 96-mar97 Page 14

Child nutrition 1999-2000: comparing different data sources CNS:age gp 6-71 mos, 442psu (252 R+190U), 3059hhs, 4000 childn, feb 2000-feb2001 DHS: <5y, 341psu (242R+99U), 10,268 hhs (6939 childre), nov1999-mar 2000. NSP: Page 15

Child nutrition 2005: comparing different data sources NNP sample size: more than 26000 Page 16

Probable reasons for data discrepancy among sources Inaccuracy in age reporting due to lack of birth record Age group studied Time of data collection Definition of location DHS1996-97 used the Integrated Master Sample (IMPS) of the BBS which categorizes ‘other urban areas’ (thana hq, smaller towns) as rural areas. So rural-urban differentials in DHS 1996-97 are not comparable to DHS 2000 Errors in age data affect the value of an index indirectly through the value in the reference population. An overestimate of age will result in a higher-than-actual wa value and will underestimate the z score. Similarly, an underestimate of age will overestimate the z score. WAZ=Wcurrent-wt in refe age/sdof weight in ref age Page 17

Sources of data on food security Household Income and Expenditure Survey (HIES) Done by BBS 1973-74, 1981-82, 1983-84, 1985-86, 1988-89, 1991-92, 1995-96, 2000, 2005, 2010 Among others, provides information on: Household income and expenditure Daily per capita intake of different food items hh food security Average calorie and protein intake Other related data on food security include: health status child immunization pre- and post-natal care participation in social safety nets housing, water and sanitation Page 18

Sources of data on food security…….cont’d Welfare Monitoring Survey Conducted for the first time in 2009 Records data on standard of living indicators on non-income dimension Asks direct questions on food security Food Security and Nutritional Surveillance Project (FSNSP) Collects food security data on a seasonal basis housing and housing facilities, health status, self assessment of poverty, food security, clothing, footwear, crises coping, credit and inv, club and society, security situation, women empowerment, recreation and leisure. WMS– hhs having necessary income to feed hh members 3 times daily, coping strategies for hhs with not sufficient income/food production, no of days in a week that less food was taken, length of crisis, reasons for food crisis etc. Page 19

Bangladesh Integrated Household Survey 2011-2012 Nationally representative survey being conducted by IFPRI to yield integrated hh data for policy analyses 6500 households; survey completion in April 2012 Detailed information on food security – captures both hh as well as intra-hh food consumption and also food frequency Detailed plot-level data on agriculture Detailed nutrition module, including anthropometry, IYCF, micronutrient consumption, exposure to national IYCF communications campaign, use of health and nutrition services Nationally rep at rural level and also divisionally representative. Page 20

Anticipated nutrition-related outputs from BIHS data National food and nutrition profile disaggregated by division: gender differentiated analysis Status paper on SUN and SPRING interventions Nationally representative findings on exposure to national IYCF media campaign Analytic papers on Determinants of use of nutrition-related services Women’s assets and child nutrition Household food security and child diets/child nutrition Agriculture and nutrition linkages Regional dietary diversity Micronutirent status by gender. SUN global initiative, policy dialogue on nutr, consultattive gp on advansing proposal, action planning and scaleup process with the Gob. Strengthening partnerships, results and innovations in nutrition globally (SPRING) U can do cross tab say nutri with agroeconomic zone. Page 21

Different units of analyses Food security indicators are mostly collected at the household level or community level while Nutrition indicators are collected for individual and infant-mother pairs So how do we integrate these two indicators? Different units of analysis Nutrition surveys are expensive Page 22

Integrating data on food security and nutrition security Food security indicators may be used in conjunction with health and care practice indicators for possible cause of malnutrition For e.g. link between income and expenditure (food security indicators) and health (diarrhea) with malnutrition Agriculture productivity or homestead food production can be linked with nutrition status Diversification of agriculture production can be linked to nutrition status Page 23

Integrating data on food security and nutrition security……cont’d Assessment to improve health and nutrition programming may be used to obtain food security related information, particularly on food consumption and infant feeding practices Household’s perception of its own food security standing and nutrition status of children in the household Household’s energy and protein intake and the nutrition status. Page 24

Best practice to integrate food security and nutrition for program assessment Standardized questionnaires and checklists should be used in repeat surveys while nutritional status should continue to be collected at the individual level. Food consumption data (24-hour recall, 7-day recall) must complemented with data on market availability and food prices so as to link the availability, access and utilization components more rigorously. Page 25

Needs assessment process for project implementation 1. Collate nutritional data from as many different population-based sources as possible 2. The information should be arranged by indicator, age group studied, and year of collection 3. Conflicting evidence from different sources should be carefully reviewed with the help of local experts to identify the source of the discrepancy. 4. Subsequently, it may be helpful to rank the different problems identified according to their frequency in the population Page 26

Thank you! Page 27

Agriculture Nutrition Health AGRICULTURE – NUTRITION - HEALTH HEALTH & NUTRITION BENEFITS AGRICULTURE THROUGH: AGRICULTURE BENEFITS NUTRITION + HEALTH THROUGH: Productivity Agriculture Livelihoods Income Risk taking Employment Education Nutrition Food security Cognition Dietary diversity Endurance Gender equity Physical strength Talk about women’s time – child care, etc.; status/intra-hh decision/resource allocation; women’s nutrition Let me start with an overview of the linkages between agric health and nutrition Agriculture intensification plays an important role in emerging diseases, most of which from livestock, which are of increasing global and regional concern. Agriculture affects health Health affects agriculture Poverty is entwined with both….as is nutrition …but the two sectors do not communicate Potential “win-win” solutions to shared problems Globalization, food & fuel price volatility, emerging disease, environmental degradation, climate change raises urgency Health AGRICULTURE POSES RISKS: Water-related diseases Food-borne diseases Zoonotic diseases

Health Nutrition Agriculture Figure 1. CRP4 Conceptual Framework Enhancing Nutrition along the Value Chain Component 1 Prevention , Control of Ag- Associated Diseases Component 3 Integrated Programs and Policies Component 4 Biofortification Component 2 Nutrition Agriculture Social Behavior Change and Communications All components Availability, access, intake of nutritious, safe foods Knowledge of nutrition, food safety Labor productivity Income and gender equity Risk of AAD RESULT: A better nourished, healthier population, esp.mothers and children < 2

Example: A Nutrition-Sensitive Value Chain for Beans (Uganda) Value Chain Steps Activities to Enhance Nutrition Field trials with new varieties Soil & terrain analysis; trainings Inputs into production Production Technologies to  losses (insects) Nutrient retention analysis Post-harvest handling/storage, processing Testing sequencing + duration of different processing techniques (nutrient retention, anti-nutrients) Analysis of main market channels, Drivers of market decisions, Presence of nutrient-enhanced foods Marketing Activities at the different leverage points along the supply chain Example of coordination across different actors along the chain and activities/interventions done by a wide range of stakeholders – farmers, NGOs, researchers, private sector OBJECTIVES: IMPROVE YIELDS/PRODUCTIVITY; IMPROVE NUTRIENT CONTENT (RETENTION + ANTINUTRIENTS); AND UNDERSTAND AND RESPOND TO THE DEMAN (E.G. FOR PRODUCTS WITH SHORTER COOKING TIME) Soaking, de-hulling, sprouting (germination). ADDING BOTH ECONOMIC AND NUTRITIONAL VALUE; FOCUSING ON PRODUCTION, INCOME AND CONSUMPTION MULTIPLE STAKEHOLDERS + ACTORS (FARMERS, NGOS, PRIVATE SECTOR, RESEARCHERS, ETC.) Leverage points: Key points during the production, processing and distribution of a food product where nutritional value can be added. Activities: Actions required in order to work towards the goal. Increased availability of, access to, and demand for NUTRITIOUS BEANS Consumer surveys Cooking trainings, Education, Behavior chance communications Source: Adapted from Mazur et al. 2009. Pulses CRSP

Conclusions Agriculture alone will not improve nutrition fast enough We have opportunities and examples of success on how to bridge the agriculture-nutrition divide We have challenges Our biggest challenge AND opportunity is to work together - cross-sectorally (how?) We need to do much better at documenting successes – and failures; we need the evidence for advocacy, to stimulate investments In Bangladesh we have a momentum, new initiatives, committed government and donors, experienced NGOs, strong research community and partners 2: we need to build from those; we need more successes, more examples, more evidence WE NEED TO TRANSLATE ALL THIS INTO QUICK AND SUSTAINED GAINS FOR NUTRITION We need the evidence: for advocacy, for lessons learned – scaling up, for PROGRESS Agriculture alone will not improve nutrition FAST ENOUGH