1. THEME 1: DATA REVOLUTION AND INNOVATIVE APPROACHES FOR ASSESSING PROGRESS IN NUTRITION OUTCOMES Suneetha Kadiyala Senior-lecturer in Nutrition Sensitive Development London School of Hygiene & Tropical Medicine (LSHTM), UK Leverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH)

2. SDG2: TARGET 2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older p ersons.

3. GLOBAL NUTRITION TARGETS AND PROGRESS TO DATE

4. WHAT ARE THE GLOBAL NUTRITION TARGETS We had one nutrition target for MDG1 6 World Health Assembly Targets

5. Maternal only in one target!!

6. WHAT ARE THE GLOBAL NUTRITION TARGETS We had one nutrition target for MDG1 6 World Health Assembly Targets

7. Source: Global Nutrition Report, 2015

8. NUMBER OF COUNTRIES ON COURSE TO MEET 5 WHA TARGETS Source: Global Nutrition Report, 2015

9. SDG2: TARGET 2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons Anemia WHA target?

10. CHILD ANTHROPOMETRY INDICATORS

11. NUTRITION INDICATORS REVIEWED AT THE SECOND IAEG-SDG MEETING o Consensus on stunting and wasting Both are green indicators o But no other specific indicators are listed to evaluate progress on other nutrition outcomes and populations of interest to SDG2. But commitment to internationally agreed nutrition targets articulated Source: Results of the list of indicators reviewed at the second IAEG-SDG meeting, 2 nd November 2015

12. WHAT DO WE KNOW ABOUT THE GREEN INDICATORS?: STUNTING AND WASTING (OVERWEIGHT) Standard nutrition indicator?Yes Chronic undernutrition: HAZ<-2SD ; Acute malnutrition: WHZ<-2SD* Overweight: WHZ>+2SD Scientific consensus?Yes, but… Widespread current data systems available? Yes Populations surveys such as DHS & MICS Coverage and representativeness Nationally representative At the disaggregated level, representative at urban/rural; state/province level

13. BUT HOW WELL DO WE MEASURE AND TRACK ACUTE MALNUTRITION? (1) o Nutritional oedema not included in the WHO classification of wasting o Most population surveys do not routinely measure mid-upper arm circumference (MUAC) Moderate acute malnutrition: MUAC ≥115 mm and <125 mm Severe acute malnutrition: MUAC<115mm o MUAC and WHZ indicators report a similar prevalence of acute malnutrition, but identify different children 40-60% overlap

14. BUT HOW WELL DO WE MEASURE AND TRACK ACUTE MALNUTRITION? (2) o Should MUAC be considered as a standard indicator for wasting for SDG2? Better at early detection of acute malnutrition Better predictor of mortality than the WHZ Independent of body shape Recommended programmatic approach to screen for treatment o Current global estimates probably underestimate the actual annual burden of wasting Wasting is episodic Current surveys miss a relatively large proportion of incident cases occurring overtime Seasonal peaks are probably underestimated

15. Issues that need to be tackled o Frequency of data collection across ALL LMICs o Improve sampling methodology to monitor vulnerable populations and equity in progress Migrants and displaced persons Ethnic minorities o Include older children and adolescents (5-19 years) in anthropometry measurements o Improve data systems to measure incidence of acute malnutrition

16. IMPROVE DATA ON ACUTE MALNUTRITION 1.Include the following in current populations surve ys  MUAC  Nutritional edema 2.Invest in research to resolve the MUAC and WHZ debate  What makes sense for ongoing monitoring and evaluation if these measures identify different children, even though the overall prevalence estimates tend to be similar? 3.Improve incidence data. But how?  Establish data systems in high burden countries  Frequent (2-4 times/year) data collection  Sentinel sites? Repeated small-scale surveys?

17. DATA FOR OTHER INTERNATIONALLY AGREED TARGETS

18. WHAT DO WE KNOW ABOUT LOW BIRTH WEIGHT? Standard nutrition indicator?Yes Wight at birth<2500gms Scientific consensus?Yes Widespread current data systems available? NO No time series national level estimates DHS & MICS (about ½ data points) National household/facility based surveys (about 1/3 rd data points) Administrative records (1/5 th ) Several methodological challenges Coverage and representativeness Only ½ the children weighted at birth (excluding China) A study by UNICEF, JHU and LSHTM will provide estimates and time trends But investments in data systems will need to be made

19. ANEMIA AND OTHER MICRONUTRIENT DEFICIENCIES Standard nutrition indicator? Yes, only for anemia Scientific consensus? Yes on anemia, but does not take into account the burden Thalassemias, which remains under investigated Yes, for some other MNs. But Vitamin A, Zinc and Iodine measured by coverage, not the right indicators to assess the change in nutrition status Widespread current data systems available? NO For anemia, DHS and MICS could more consistently collect data on anemia using the current assessment methods Special surveys by WHO Vita- min and Mineral Nutrition Information System (VMNIS), but not currently amenable for consistent monitoring Data on prevalence of micronutrient deficiencies is patchy at best Field friendly assessment methods for micronutrient biomarkers need to be developed, tested and scaled up -Example, dried blood spots

20. MINIMUM DIETARY DIVERSITY AS A PROXY INDICATOR FOR DIET QUALITY AS SDG2:2.2 TARGET o Currently not among the WHA nutrition targets, but embedded in SDG2: 2.1 o But central to SDG2 theory of change o Individual DD scores (IDDS) are valid proxy indicators of diet quality (access) women (micronutrient adequacy) children (density of the diet) o Need to be tested for cross-country comparisons Careful validation of these indicators for different purposes (for example, monitoring, evaluation, targeting) needed o Should be included consistently in population surveys (several DHS surveys already include this)

21. THE ELDERLY…

22. NUTRITION IN ELDERLY o Height based indicators inappropriate o ?experience based indicators? o Need a strong push to Identify which nutrition indicators to measure Develop and validate field friendly assessment methods o Develop/expand data systems

23. DATA SYSTEMS ARE INADEQUATE Source: Global Nutrition Report, 2015

24. INVESTMENTS REQUIRED (1) o Anthropometry Improve coverage, frequency and harmonization of population surveys for cross-country comparison Consider inclusion of edema and MUAC Improve sampling methodologies to cover vulnerable groups and adolescents and track equity in progress Invest in building surveillance systems to track incidence on acute malnutrition o Experience based proxy indicators of diet quality Continue embedding MDD indicators in the population surveys Validate for cross-country comparison But where are women? Need for inclusion of nutrition outcomes among women explicitly as key SDG 2.2 indicators. BMI based indicators for chronic energy deficiency and overweight Experience based indicators (W-MDD score) Anemia Notice: the current nutrition targets do not have any other nutrition-related chronic diseases beyond overweight and obesity.

25. INVESTMENTS REQUIRED (2) o Micronutrient status Continue to include Hb in current population surveys Invest in field-based methods to assess multiple biomarkers Investigate how to institutionalize WHO-VMNIS in parallel with population surveys or embed them in national nutritional surveillance systems o Low brithweight need nationally representative systems o Nutrition in elderly Need to start with the basics!