1. Module 5: Nutritional assessment in policy and programmatic application By Tina G. Sanghvi, PhD Senior Country Director Alive & Thrive, FHI360 Training on Assessment of Nutritional Status 18-22 December 2011 Date : 22 December 2011, Venue: FPMU Meeting Room The Training is organized by the National National Food Policy Capacity Strengthening Programme (NFPCSP). The NFPCSP is jointly implemented by the Food Planning and Monitoring Unit (FPMU), Ministry of Food and Disaster Management and Food and Agriculture Organization of the United Nations (FAO) with the financial support of the EU and USAID.

2. Acknowledgements M. Ruel, IFPRI. Nutrition and economic growth A&T Partners’ Meeting Hanoi, September 2011 Lalita Bhattacharjee, FSNSP Dissemination Workshop. December 13 December 13, 2011. Mahbub Hossain, BRAC. FSNSP Dissemination Workshop. December 13, 2011 John B. Mason. Keynote paper: Measuring hunger and malnutrition.FAO Symposium 2002 IFPRI. Alive & Thrive Baseline Survey 2011. Haider, Sanghvi et al. Alive & Thrive Formative Research on IYCF. 2009. Module 5: Program and Policy Application, Tina Sanghvi PhD

3. Session Overview Uses of data for policy & programs – Examples Why dietary adequacy does not always equal nutritional status – Examples Module 5: Program and Policy Application, Tina Sanghvi PhD

4. Indicators – Country Investment Plan Module 5: Program and Policy Application, Tina Sanghvi PhD Key Indicators Baseline (‘07-’10)Final ‘15-’16) Overall goal: % People undernourished2717.5 % Child stunting4325 % Child underweight4133 Outcome/impact: Food availability (food supplies)(rice supply & share) Food access (income) - Poverty rate < 2022 kcals/day4024 - Poverty rate < 1805 kcals/day19.514 Food utilization - Minimum acceptable complementary feeding (quantity & quality of CF 6-23 m) 4256

5. Uses of data for policy & programs How food & nutrition assessments are used: – Define trends to trigger action – Identify causes to design interventions – Monitor & evaluate effects of programs & policies Choice of indicators & interpretation are key Example: In Bangladesh, food and poverty trends have improved. Fertility & mortality rates have declined but malnutrition is stagnant. This is triggering actions to find out the causes, evaluate past programs and strengthen nutrition interventions, e.g. CIP, NFP, POA, National Nutrition Service to evaluate their future effects Module 5: Program and Policy Application, Tina Sanghvi PhD

6. METHODS OF ASSESSING FOOD SECURITY& NUTRITION & THEIR USE MethodUse Trends analysis Research into causes Evaluation (1 ) FAO: DES/CV dietary energy supply Main use: global and regional level; always under-estimates Not very useful except for broad inter-country trends Not very useful (coefficient of variation) (2) Household income and expenditure survey Useful: national and subnational level Can be useful Useful (3) Food consumption/Useful: now available at the national level, thus very useful, captures intra-HH food distrib. Main use individual intake (24- hour) (4) Anthropometry (mother, child weight & height) Useful at all levels, but for physical malnutrition and not food security Useful for physical malnutrition not food security Useful but should also have food security indicators (5) Qualitative method (food habits) Useful: national and subnational level Useful

7. Questions that can be addressed by different methods MethodUse Trends analysis Causal analysisEvaluation (1 ) FAO: DES/CV dietary energy supply Is the supply of food in terms of calories/ energy improving to meet needs, if equitably distributed? Is the cause of food insecurity & undernutrition due to overall food supply? Are food supply policies/programs working? Impact of climate change/ disasters on supplies? (coefficient of variation) (2) Household income and expenditure survey Are no. of food secure HH (in energy and nutrients) improving? Is the cause of problems due to low expenditures on food? Are programs working to reach the poor? (3) Food consumption/Are mothers and young children consuming more adequate diets? Is the problem food availability/access or dietary habits? Are programs for women and young children working? individual intake (24-hr) (4) Anthropometry (mother/child wt, ht) Is nutritional status improving? No Does the program improve nutrition of mothers & children? (5) Qualitative method (food habits, frequency) Are food habits improving? Are habits a barrier? Does the program improve food habits?

8. How we present and interpret data makes a difference: examples Module 5: Program and Policy Application, Tina Sanghvi PhD

9. Trends in food intake (gms/capita/day) AllUrbanRural 1991-92 886938 878 1995-96 914931 911 2005 949952 946 201010009851005 Module 5: Program and Policy Application, Tina Sanghvi PhD Intakes improving faster in rural areas, Averages hide disparities among economic groups

10. Food available in grams per head per day Module 5: Program and Policy Application, Tina Sanghvi PhD

11. Diversity: -National supplies -Household level - Child’s diet -Women’s diet Module 5: Program and Policy Application, Tina Sanghvi PhD

12. Trends in food content adequacy (gms/capita/day) FoodRecom.20052010Trend Rice390440416 Wheat1001226 Vegetables225220236 Pulses3014 Oil201621 Fish454249 Meat/eggs342025 Module 5: Program and Policy Application, Tina Sanghvi PhD

13. Content of food basket: improving diversity Module 5: Program and Policy Application, Tina Sanghvi PhD

14. Content of food basket: gaps in diversity Module 5: Program and Policy Application, Tina Sanghvi PhD

15. Dietary intake assessment is key RAP –low cost, primary method for collecting dietary data (locally available /commonly consumed foods, dietary habits, behaviour) Household surveys – provide data on foods consumed by HH not individuals Point to which foods are major contributors to nutrients of particular concern ( identify vulnerability/at risk of dietary deficiency - e.g lack of animal foods; no fresh vegetables/fruits, lack of DGLV/YOV–lack of vit. C & A in diet) Food record and 24 hr recall methods of choice for estimating mean intakes; quantitative dietary intake methods to obtain individual nutrient intakes Take measurements for each individual on at least 2 non- consecutive days to obtain intra-individual variation Module 5: Program and Policy Application, Tina Sanghvi PhD

16. Why improving food security does not necessarily remove undernutrition Module 5: Program and Policy Application, Tina Sanghvi PhD

17. Ruel; A&T Partners' Meeting, Hanoi 9/27/2011 Module 5: Program and Policy Application, Tina Sanghvi PhD

18. Factors that determine nutritional status Module 5: Program and Policy Application, Tina Sanghvi PhD

19. Adequate Complementary Feeding BDHS 2007

20. Quality of Children’s Diets (BDHS, 2007)

21. Why is nutrition not improving? Knowledge: do people know what foods they should consume by age, sex, occupation, physiological status? Do families have the resources/motivation to convert knowledge to practice If food intakes (energy and nutrients) are adequate, could there be intervening factors e.g. illness Pre-disposing factors: maternal undernutrition seasonal food/income shortages, migration, illness outbreaks, hygiene/sanitation, emergencies Importance of under 2’s Module 5: Program and Policy Application, Tina Sanghvi PhD

22. Illustration of association between dietary adequacy and anthropometry 100 80 20Total sample 70 0% > -2SDs 30 10 20% <-2SDs Total under or adequate nutrition % with adequate diet % with inadequate diet Prevalence of under nutrition Source : Mason, 2002 in “Measurement and Assessment of Food Deprivation and Undernutrition”, FAO Note: 10% have adequate diets but are still undernourished due to other causes

23. New focus on under 2 yr age group Most rapid decline in nutritional status Damage is largely not reversible Affects child growth + adult chronic diseases Affects brain development/learning as well as physical development All national nutrition indicators focus on young children, to improve MDG 1 have to prevent under 2 decline in nutrition Module 5: Program and Policy Application, Tina Sanghvi PhD

24. Goal: To reduce undernutrition, improve IYCF Maximum decline at 3 to 15 months – period of IYCF EBF ------- Complementary Feeding --------------------------- Growth of girls/ boys NCHS/WHO standards Growth data: Kuntal K. Saha et al, Food Nutr Bull. 2009; 30: 137-44 ICDDRB Module 5: Program and Policy Application, Tina Sanghvi PhD

25. CF Provides Adequate Energy & Nutrients 200 300 550 ½ Bati 2 times Daily + ½ Bati 3 times Daily + 1 Bati 3 times Daily+ Bati = 250 ml At least 4 types Hygienically prepared Exclusive BF BF + CF Recommended diet : Module 5: Program and Policy Application, Tina Sanghvi PhD

26. Indicators – Country Investment Plan Module 5: Program and Policy Application, Tina Sanghvi PhD Key Indicators Baseline (‘07-’10)Final ‘15-’16) Overall goal: % People undernourished2717.5 % Child stunting4325 % Child underweight4133 Outcome/impact: Food availability (food supplies)(rice supply & share) Food access (income) - Poverty rate < 2022 kcals/day4024 - Poverty rate < 1805 kcals/day19.514 Food utilization - Minimum acceptable complementary feeding (quantity & quality of CF 6-23 m) 4256

27. Minimum acceptable diet for under 2’s 3 conditions must be met: – Breastfeeding – Meal frequency as per age (2 to 3 times plus snacks) – At least 4 different categories of food Analysis should be used to focus BCC messages, how to deal with HH food availability, mothers’ time constraints etc. Module 5: Program and Policy Application, Tina Sanghvi PhD

28. Gaps in feeding BDHS 2007, WHO (HKI 2006) Median EBF 1.8 m Breastfeeding Module 5: Program and Policy Application, Tina Sanghvi PhD

29. Main messages What is needed to ensure food security & nutrition results: – Food availability - Food access - Food utilization – Behavior change communications to promote specific dietary & health habits Disaggregated analysis of trends, causes & evaluations to design relevant interventions Equity: rational use of foods to reach the disadvantaged & high risk ages; targeted nutrition Module 5: Program and Policy Application, Tina Sanghvi PhD

30. Conclusion Understanding what indicators & assessment methods to use in policy & programs is key Food & dietary adequacy (total energy & diversity) is a necessary, but not sufficient condition for good nutrition Interpreting and presenting data in an accurate and relevant manner is essential Assessments that do not lead to actions are meaningless Module 5: Program and Policy Application, Tina Sanghvi PhD