1. Prevention of stunting- a development challenge; food/nutrient based approaches, the way forward Dr. Khizar Ashraf United Nations, World Food Programme

2. Intended Discussion Nutrition Status of Under 5 Children in Pakistan and the issue of food insecurity Why Malnutrition Matters The window of opportunity (1000 days) Prevention of Stunting possible food based approaches Ongoing Evidence building in Pakistani context

3. Malnutrition - responsible for about 1500 deaths globally, mostly women, infants and children, during this presentation! These deaths are preventable! These deaths are preventable!

4. Some Major World Risk Factors Causing Deaths Malnutrition accounts of ≈ 30 million deaths per year (about 1 death per second)

5. Death Figure from WHO, 2000

6. The Issue < 5 Indicators NNS 2011 32.7%, 30.3% and 40 % are suffering from Iron, Vitamin A and Zinc deficiency respectively, where as 62.5% are anemic

8. Anemia Vitamin A Vitamin D Zinc

9. Micro-nutrient Deficiency: Iodine Adequate level of iodine status at national level documented in NNS 2011. Significant improvement in the use of Iodized Salt in 2011 compared to the result of 2001 NNS. Yet Pakistan lags behind the international USI target coverage of 90% and above.

10. Why Malnutrition Matters 10

11. The Outcome: Vicious Cycle of Poverty and Malnutrition- Estimated effect on Pakistan Low food intake Frequent infections Hard physical labor Frequent pregnancies Large families Income poverty Malnutrition Direct loss in productivity from poor physical status Loss in resources from increased health care costs of ill health Indirect loss in productivity from poor cognitive development and schooling Overall loss to the economy of 2-3% of GDP annually

12. Evidence shows the “window of opportunity” is small…with a large part of the damage happening before and shortly after birth… 12 Why Malnutrition Matters Source: Victora CG, et al. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print) Mean height for age z-scores by age By region (0-59 months)

13. Nutrition and Early Childhood Development Source: Perry (2004) Abnormal Brain Development Following Sensory Neglect in Early Childhood.

14. Major contributing factors in Pakistan –Inappropriate IYCF practices; late initiation breast feeding - only 37% exclusively breastfed. –Household food insecurity is 58% country wide, 72% in Sindh –Household income minimal - subsistence –Poor quality and insufficient amount clean water –Poor sanitation - 48 million people practice open defecation –Early and frequent childbearing ( 50% of girls are married by the age of 18 years, 15% by the age of 15, PDHS 2006- 07) –Low literacy rate - 47% –Frequent emergencies

15. Challenge

16. Why to engage in Prevention of Stunting

17. How to move towards prevention of stunting

20. Prevention of stunting project Thatta- Sajawal: utilizing the window of opportunity for addressing stunting in children under 5

21. Objectives of the Project To reduce stunting in children 6-23 months using a locally produced LNS type (Wawamum) and promoting appropriate IYCF practices (including promotion of exclusive breast feeding until 6 months). To reduce micronutrient deficiencies in children 24-59 months using multi micronutrient powders, MNP,, along with appropriate behavior change communication. To improve maternal/PLW nutritional status and to have an impact on the birth outcome (reduce low birth weight), To study effectiveness of food based approach to address stunting Lipid- based nutrient supplement

22. Evidence Building in Pakistani Context: Research component To assess the effectiveness of the food/nutrient -based interventions on reduction of stunting among children under two. To assess the design and operational factors at the different stages of the programme cycle that may have affected the outcome. To determine unintended consequences of the interventions, both positive and negative. To determine cost-effectiveness. To provide recommendations for improved programme design and evaluation. To know the optimal length of preventive intervention. To compare the use of specialized nutritious foods over other interventions, such as conditional cash transfers for stunting prevention.

24. Thank you 24