1. Food & Nutrition Situation
in Bangladesh
Dr Tahmeed Ahmed
Director
Centre for Nutrition & Food Security ICDDR,B
Professor, Public Health Nutrition
James P. Grant School of Public Health, BRAC University

3. Intergenerational Cycle of Malnutrition
ADULTS
Malnourished
Adolescent
Stunted
Pregnancy
Low Weight
Gain
Child
Baby
Low Birth
Weight
Higher
maternal
mortality
Reduced
mental
capacity
Foetal
Malnutrition
rate
Impaired
development
Untimely / inadequate
weaning
Frequent
infections
Inadequate
food, health
& care
Llanos, Alvear, Uauy 2004

4. Different Types of Childhood Malnutrition
Wasted
Low weight for height
Stunted
Low height for age
Underweight
Low weight for age
Normal
Normal height for age
Children

5. Stunting in Early Childhood & Later Development Outcomes
Philippines, n=2489
Not stunted
Mildly stunted
Moderately/severely
stunted
Mendez MA, 1999

6. UNICEF; Black R, 2008

7. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh10 20 30 40 50 60 70 80
2004
2007
Percentage below -2SD
NCHS/WHO Reference
Ahmed T et al. In press.

8. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh10 20 30 40 50 60 70 80
2004
2007
Percentage below -2SD
NCHS/WHO Reference
Reasons for the decline:
Increased literacy Fertility rate reduced
Measles vaccination now at 83% Family size smaller
Vitamin A supplementation coverage at 88% Rural electrification
Increased food production & energy intake Microcredit?
Ahmed T et al. In press.

9. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh10 20 30 40 50 60 70 80
2004
2007
Percentage below -2SD
NCHS/WHO Reference
Ahmed T et al. In press.

10. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh10 20 30 40 50 60 70 80
2004
2007
Percentage below -2SD
NCHS/WHO Reference
Assumptions on reasons for the stagnation:
Increase in inequity (increase in Gini coefficient)
Reduction in infant mortality rate resulting in more infants surviving but
with malnutrition
Ahmed T et al. In press.

11. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh10 20 30 40 50 60 70 80
2004
2007
Percentage below -2SD
NCHS/WHO Reference
Required rate of reduction, 1.36 percent points/yr
Rate of reduction so far, 1.27 percent points/yr
2015
Ahmed T et al. In press.

12. Malnutrition is more common in Asia than in Sub-Saharan Africa60
47.0
47.8 50
44.9
38.5 40
35.6
Percentage below -2SD
NCHS/WHO Reference 30
22.6
20.2 20 10
Nepal 2006
India
Ethiopia 2005
Rwanda 2005
Uganda 2006
Cambodia 2005
Bangladesh 2007

13. Trends of BMI of Women in Bangladesh60
52.0 50
45.4 40
34.3
29.7
Percent of women with BMI <18.5 30 20 10
2004
2007

14. On the Causes of Malnutrition
Population increases in a geometric ratio, while the means of subsistence increases in an arithmetic ratio
Thomas Malthus ( )

15. Limited Land Mass with the Highest
Population Density
Population density in Bangladesh is 3 to 40 times higher than other ‘mega’ countries
Bangladesh
Japan
Pakistan
India
Indonesia
China
USA
Nigeria
Mexico
Russia
Brazil

16. Korail Slum

17. Korail Slum Close to 27% or 40 million live in urban areas
About 40% of Dhaka city population lives
in slums
Dhaka is the fastest growing city
Korail Slum

18. On the Causes of Malnutrition
Famine and malnutrition are a result of a collapse of entitlements for a certain segment of society and the failure of the state to protect those entitlements.
Amartya Sen

19. Poor maternal nutrition Low birth weight Low rates of EBF
Poverty
Food insecurity
Poor maternal nutrition
Low birth weight
Low rates of EBF
Lack of proper CF
Frequent illnesses
BBS, World Bank, WFP 2005

20. Food Security in Urban Slums
Household consumption
Dhaka
Chittagong
Khulna
Rajshahi
All
<2,122 kcal/person/d
42.4
56.0
52.0
61.3
47.8
<1,805 kcal/person/d
24.2
35.8
38.5
36.0
29.0
Urban food security Atlas, 2008

21. Share of Energy Intake in Bangladesh
Staples
Non-staple
plants
Fish and
animal
Howarth Bouis, 2006

22. Slum Non-slum Underweight (BMI <18.5) 26.7 12.9
Over weight (BMI ≥25)
14.8
34.2
Diabetes mellitus
5.5
17.0
Hypertension
12.1
21.4
Carbohydrates in diet
‘Fast food’ culture
- Lack of exercise

23. Severe Acute Malnutrition
2.9% in Bangladesh
~500,000 children
At risk of death from
Hypoglycemia
Hypothermia
Infections

25. A 2 yr old girl with dysentery, pneumonia
Admission
2 weeks
A 2 yr old girl with dysentery, pneumonia
Weighed only 3.8 kg
Treated with
therapeutic diets
antibiotics
micronutrients
Diagnosed TB and treated appropriately
4 weeks
5 weeks

26. Timeliness: Early Versus Late Presentation

28. There has been some improvement but much more is required

29. The Lancet Series on Maternal
and Child Undernutrition

30. Evidence-Based Interventions
Systematic review of efficacy or effectiveness of 45 possible interventions that affect maternal and child undernutrition and nutrition-related outcomes, including:
Breastfeeding promotion
Complementary feeding promotion strategies with or without provision of food supplements
Micronutrient interventions (fortification & supplementation)
General supportive strategies for improving family and community nutrition and disease burden reduction
Interventions for the treatment of severe acute malnutrition
For paper 3, the authors reviewed 45 interventions, including breastfeeding promotion, complementary feeding promotion strategies with or without provision of food supplements, micronutrient interventions, and general supportive strategies for improving family and community nutrition and disease burden reduction.
This table summarizes the various interventions with demonstrated impact on maternal and child undernutrition. Importantly, for each of the conditions contributing to nutrition-related disability and death there are already highly effective interventions available.
Bhutta ZA, Ahmed T et al. Lancet 2008 30

31. Interventions with Sufficient Evidence to Implement in All Countries
Maternal and Birth Outcomes
Iron folate supplementation
Maternal supplements of multiple micronutrients
Maternal iodine through iodization of salt
Maternal calcium supplementation
Interventions to reduce tobacco consumption or indoor air pollution
Newborn Babies
Promotion of breastfeeding (individual and group counseling)
Infants and Children
Promotion of breastfeeding (individual and group counseling)
Behavior change communication for improved complementary feeding
Zinc supplementation
Zinc in management of diarrhea
Vitamin A fortification or supplementation
Universal salt iodization
Handwashing or hygiene interventions
Treatment of SAM
Bhutta ZA, Ahmed T et al. Lancet 2008

32. Interventions with Sufficient Evidence to Implement in All Countries
Maternal and Birth Outcomes
Iron folate supplementation
Maternal supplements of multiple micronutrients
Maternal iodine through iodization of salt
Maternal calcium supplementation
Interventions to reduce tobacco consumption or indoor air pollution
Newborn Babies
Promotion of breastfeeding (individual and group counseling)
Infants and Children
Promotion of breastfeeding (individual and group counseling)
Behavior change communication for improved complementary feeding
Zinc supplementation
Zinc in management of diarrhea
Vitamin A fortification or supplementation
Universal salt iodization
Handwashing or hygiene interventions
Treatment of SAM
Hygiene interventions:
Reduce incidence of diarrhea by 30%,
reduce odds of stunting
Bhutta ZA, Ahmed T et al. Lancet 2008

33. Evidence-Based Interventions
Interventions showing the most promise for reducing child deaths and future disease burden include:
Breastfeeding promotion
Appropriate complementary feeding
Supplementation with vitamin A and zinc
Appropriate management of severe acute malnutrition
Bhutta ZA, Ahmed T et al. Lancet 2008

34. Coverage is most important !
Reduction in deaths
Reduction in stunting
% of DALYs averted
99% coverage
25%
35%
90 % coverage
22%
32%
23%
70 % coverage
17%
27%
Explain that figure shows the sort of information generated by the model. Go through what it shows – what happens to children between birth and 36 months of age – so by 36 months of age about 9% of children have died and of those who survive over half (58%) are stunted.
Bhutta ZA, Ahmed T et al. Lancet 2008 34

35. To eliminate stunting in the longer term, these
Interventions should be supplemented by improvements
in the underlying determinants of undernutrition, such as
poverty, poor education, disease burden, and lack of
women’s empowerment. 35

36. Recommendations Business as usual will not work
Need to think out of the box now
There is no one size that fits all, several strategies need to be tried

37. Recommendations
Immediate need is to improve existing services and scale them up
Primary health care focusing on child & maternal health and nutrition should be priority
Increase number of centers, staff
Improve quality of counseling
Rigorous monitoring of quality of services to reduce dissatisfaction with existing services

38. Recommendations
Primary health care intervention package should be expanded and improved
IFA tablets for adolescent girls, PLW
Breastfeeding & complementary feeding
Micronutrient powder for infants & young children
Management of moderate & severe acute malnutrition

39. Undernutrition hotspots need special attention
Monga-prone areas in the north
The coastal belt and char areas
Areas in Chittagong & Sylhet divisions with higher prevalence of child malnutrition
Rat-infested areas in the Hill Tracts
Explain that figure shows the sort of information generated by the model. Go through what it shows – what happens to children between birth and 36 months of age – so by 36 months of age about 9% of children have died and of those who survive over half (58%) are stunted. 39

40. Recommendations
But the ultimate goal is to prevent/control rapid unplanned urbanization
Create livelihoods in rural Bangladesh
Control population growth drastically
Improve livelihood & living conditions of people who are already living in urban areas