1. 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

2. Four decades of remarkable growth
Poverty declined from 75% in 1971 to 31.5% in 2010
Between 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%( ) and 39%-54% ( )]
augmented life expectancy (from 45 years to 64 years)
increased net primary enrolment ration (72.5%-108% ( )
eliminated gender gap in schooling [48%-69% ( )]
better disaster preparedness
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3. 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
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4. Trends in maternal and child under-nutrition
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5. Slow spread of these developments into nutrition
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6. 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 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
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7. 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.
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8. 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
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9. 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
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10. 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,
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
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11. Different sources of data on nutrition
Bangladesh National Nutrition Survey
, , ,
Done by the Institute of Nutrition and Food Science (INFS) under the University of Dhaka
Demographic and Health Survey
, , , 2004, 2007
Done by the National Institute of Population Research and Training (NIPORT) under the MoHFW
Child Nutrition Survey
, , 1992, , 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.
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12. 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 children
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13. 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 years and men years.
Prev BDHS included ever married women and currently married men. Now incl, never married women and formerly married men also.
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14. 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
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15. 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:
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16. Child nutrition 2005: comparing different data sources
NNP sample size: more than 26000
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17. 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
DHS 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 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
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18. Sources of data on food security
Household Income and Expenditure Survey (HIES)
Done by BBS
, , , , , , , 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
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19. 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.
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20. 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.
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21. 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.
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22. 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
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23. 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
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24. 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.
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25. 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.
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26. 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
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27. Thank you!
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28. 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

29. 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

30. 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 Pulses CRSP

31. 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