Dr Tahmeed Ahmed Director Centre for Nutrition & Food Security ICDDR,B

Dr Tahmeed Ahmed

Director Centre for Nutrition & Food Security ICDDR,B

Professor, Public Health NutritionJames P. Grant School of Public Health, BRAC University

Food & Nutrition Situation in Bangladesh

Intergenerational Cycle of Malnutrition

Llanos, Alvear, Uauy 2004

ADULTS

Malnourished

AdolescentStunted

PregnancyLow Weight

Gain

ChildStunted

BabyLow Birth

Weight

Higher maternal mortality

Reduced mental

capacity

Reduced mental

capacity

Foetal Malnutrition

Higher mortality

rateImpaired mental

development

Untimely / inadequate weaning

Frequent infections

Inadequate food, health

& care

Different Types of Childhood Malnutrition

Wasted

Low weight for height

Stunted

Low height for age

Underweight

Low weight for ageNormal

Normal height for age

Ch

ild

ren

Stunting in Early Childhood & Later Development Outcomes

Mendez MA, 1999

46

48

50

52

54

56

58

Cognitive score at 8 y

Not stunted

Mildly stunted

Moderately/severely stunted

Philippines, n=2489

UNICEF; Black R, 2008

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

10

20

30

40

50

60

70

80

198

9-19

90

199

6-19

97

199

9-20

00

200

420

07

Per

cent

age

belo

w -

2SD

NC

HS

/WH

O R

efer

ence

Ahmed T et al. In press.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

10

20

30

40

50

60

70

80

198

9-19

90

199

6-19

97

199

9-20

00

200

420

07

Per

cent

age

belo

w -

2SD

NC

HS

/WH

O R

efer

ence

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.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

10

20

30

40

50

60

70

80

198

9-19

90

199

6-19

97

199

9-20

00

200

420

07

Per

cent

age

belo

w -

2SD

NC

HS

/WH

O R

efer

ence

Ahmed T et al. In press.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

10

20

30

40

50

60

70

80

198

9-19

90

199

6-19

97

199

9-20

00

200

420

07

Per

cent

age

belo

w -

2SD

NC

HS

/WH

O R

efer

ence

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.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

10

20

30

40

50

60

70

80

198

9-19

90

199

6-19

97

199

9-20

00

200

420

07

Per

cent

age

belo

w -

2SD

NC

HS

/WH

O R

efer

ence

2015

Required rate of reduction, 1.36 percent points/yr

Rate of reduction so far, 1.27 percent points/yr

Ahmed T et al. In press.

Malnutrition is more common in Asia than in Sub-Saharan Africa

47.0 47.844.9

35.638.5

22.620.2

0

10

20

30

40

50

60

Bangla

desh 2

007

India

200

5-06

Nepal

200

6

Cambodia

200

5

Ethio

pia 2

005

Rwanda

2005

Uganda

2006

Pe

rcen

tag

e b

elo

w -

2SD

NC

HS

/WH

O R

efe

ren

ce

Trends of BMI of Women in Bangladesh

52.0

45.4

34.329.7

0

10

20

30

40

50

60

1996-97 1999-2000 2004 2007

Pe

rce

nt

of

wo

me

n w

ith

BM

I <1

8.5

On the Causes of Malnutrition

Population increases in a geometric ratio, while the means of subsistence increases in an arithmetic ratio

Thomas Malthus (1766-1834)

0

200

400

600

800

1000

1200

0 200 400 600 800 1000 1200 1400

Population (millions)

Pop

ulat

ion

Den

sity

(/ s

q.km

.)

Bangladesh

Japan

Pakistan

Nigeria

Indonesia

Mexico Russia Brazil

USA China

India

Population density in Bangladesh is 3 to 40

times higher than other ‘mega’ countries

Limited Land Mass with the HighestPopulation Density

Korail Slum

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

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

BBS, World Bank, WFP 2005

•Poverty•Food insecurity•Poor maternal nutrition•Low birth weight•Low rates of EBF•Lack of proper CF•Frequent illnesses

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

Howarth Bouis, 2006

Share of Energy Intake in Bangladesh

Staples

Non-stapleplants

Fish andanimal

- Carbohydrates in diet- ‘Fast food’ culture- Lack of exercise

Slum Non-slumUnderweight (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

Severe Acute Malnutrition

2.9% in Bangladesh~500,000 children

At risk of death from

• Hypoglycemia• Hypothermia• Infections

A 2 yr old girl with dysentery, pneumonia

Weighed only 3.8 kg

Treated with• therapeutic diets• antibiotics• micronutrients

Diagnosed TB and treated appropriately

Admission 2 weeks

4 weeks 5 weeks

Timeliness: Early Versus Late Presentation

There has been some improvement but much more is required

The Lancet Series on Maternal and Child Undernutrition

Evidence-Based Interventions

Bhutta ZA, Ahmed T et al. Lancet 2008

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

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

Evidence-Based Interventions

Bhutta ZA, Ahmed T et al. Lancet 2008

Coverage is most important !

Reduction in deaths

Reduction in stunting

% of DALYs averted

99% coverage 25% 35% 25%

90 % coverage 22% 32% 23%

70 % coverage 17% 27% 17%

Bhutta ZA, Ahmed T et al. Lancet 2008

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.

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

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

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

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

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