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Preventing disease

Promoting and protecting health

Preventing disease, promoting and protecting health

Food and Nutrition Surveillance

Christine Bocage

Sr. Technical Officer, Food Security and Nutrition

Caribbean Public Health Agency (CARPHA)

Presented at the 12th Meeting of Caribbean National Epidemiologists and Laboratory Directors

Hyatt Regency, POS Trinidad, September 17-19, 2014


Food and Nutrition Surveillance• Food and nutrition information is needed for immediate,

medium and long term decision-making relating to a country’shealth, nutritional needs, hunger, agricultural policies andprogrammes.

• This information needs to be prompt so serious consequencesof ill health will not remain unchecked and become prevalent.In many Caribbean countries, data that have been collectedrarely becomes health or nutrition information.

• What is needed are efficient Food and Nutrition Surveillance Systems


What is Food and Nutrition Surveillance?

• Food and Nutrition Surveillance is the systematic andcontinuous collection, analysis, interpretation andreporting of food and nutrition data.

• This definition denotes:

(a) monitoring the type and supply of foods at variouspoints along the food chain to see and remove obstaclesor snags quickly enough; and

(a) monitoring the nutritional status of groups at risk tofind out when and where the problems occur in orderto manage these problems.



Why are we concerned?

• Childhood obesity epidemic

• In 2010 prevalence of overweight children<5years was estimated at 42 million: close to 35million of those lived in developing countries.

• In the Caribbean obesity in <5 age group(Pre-school children) doubled over thepast decade


2010

Source: CFNI, March 2012

Burgeoning Obesity

0

5

10

15

20

25

30

%

Proportion of overweight children in the region

at risk of overweight overweight


Source: School Health data, 2000

Obesity, majorrisk factor forNCDs

Adolescentpopulationobesity up to14%

Burgeoning Obesity

0

2

4

6

8

10

12

14

16

18

85th-95th P 95th P

Overweight among 10-14 yr old - St Vincent

male

female


Boys

N=812

Girls

N=1049

Source: CFNI/WDF Project (2007-2011)

Nutritional status of Caribbean children 11-13 years old (2008)


Prevalence of Overweight/ObesityCountry Publication Year Obese/Overweight

Antigua(4-20 years)Walwyn, L. et al

2012(4029 students)

Overweight -20.5% ; Obese - 6.3%

Bahamas(Grade 10/Form 4) Taylor, S. et al

2011(719 students)

Overweight – 13.9%; Obesity – 14.0%

Rivers, K.L. et al 2013(861 students)

Overweight – 15%; Obese -15.2%;severely obese -7.9%

Barbados(11-16 years)

2007(400 students)

Overweight – 32.0%; Obesity – 19%

Jamaica(6 -10 years) Blake Scarlett, B. E. et al

2013(5710 students)

Overweight – 10.6% Obese – 7.1%

(12-17 years)Ross, S. et al

2013(220 students)

Overweight – 16.7% Obese – 13.3%%


Prevalence of Overweight/ObesityCountry Publication Year Obese/Overweight

Turks and Caicos(Grades 5&6 – Stds 4&5)Malcolm, S. et al

2013(297 students)

Overweight/Obese – 35%

Trinidad and Tobago(5-18 years)Ministry of Health and CFNI

20102830 (53.4%)Primary school children

2471 (46.6%) Secondary school children

Primary Schools Overweight or Obese – 23%;

Secondary School Overweight or Obese – 26%

Trinidad and Tobago(7-18 years)Batson, Y. et al

2012(2066 students)

Overweight – 17%; Obese – 15%



• At present we cannot make a definitive statement on thenutritional status of the populations of the region. We haveperiodic surveys (MICS; SLC; Poverty Assessments; GSHS(Global School Based Student Health Survey; STEPS Survey)but not surveillance data.

• Many countries collect some data and analyse while others donot: what is collected is sometimes piecemeal and may onlyfocus on the under 5 and children at entry to and exit fromPrimary School.

• There is rarely any data management system.



Food and Nutrition Surveillance is also important todocument milestones in the achievement of the NCD GlobalTargets as well as initiatives such as:

• Millennium Development Goals (8 Goals; 21 targets and 60indicators)

• Goal 1: Eradicate extreme poverty and hunger

• Goal 2: Achieve universal primary education

• Goal 3: Promote gender equality and empower women

• Goal 4: Reduce child mortality

• Goal 5: Improve maternal health

• Goal 6: Combat HIV/AIDS, malaria and other diseases

• Goal 7: Ensure environmental sustainability

• Goal 8: Develop a Global Partnership for Development

• The Port of Spain Declaration

• The UN High Level Meeting; to name a few.



Indicators:

• These should be defined in practical terms and the most usefuland effective indicators selected.

• The following are suggested core and minimum corenutrition indicators that should be collected and reported onby all the countries.

• Some are already being measured in countries. However, thesystem needs to focus on the analysis and reporting of theseindicators.



Children (<5 years of age)

Proportion of children underweight (weight for age below - 2SD)

Proportion of children severely underweight (weight for age below - 3SD)

Proportion of children wasted (weight for length/height below -2SD)

Proportion of children severely wasted (weight for length/height below -2SD)

Proportion of children stunted (length/height for age below -2SD)

Proportion of children severely stunted (length/height for age below -3SD)

Proportion of children at risk of overweight (BMI for age or weight for length/ height above 1SD)

Proportion of overweight children (BMI for age or weight for length/ height above 2SD)

Proportion of obese children (BMI for age or weight for length/ height above 3SD)

Percent of infants exclusively breastfed through 6 months of age

Percent of live births weighing less than 2,500 grams

Percent of live births weighing more than 4,000 grams

Proportion of children with anaemia (Hb <11 g/dl)

Older children (5 – 19 years of age)

Proportion of underweight schoolchildren (weight for age (up to 10 years) below -2SD)

Proportion of severely underweight schoolchildren (weight for age (up to 10 years) below -3SD)

Proportion of children stunted (height for age below -2SD)

Proportion of children severely stunted (height for age below -3SD)

Proportion of overweight children (BMI for age or weight for height above 1SD)

Proportion of obese children (BMI for age or weight for height above 2SD)

Proportion of children with anaemia (Hb <11 g/dl)

Adults and Pregnant women

Proportion of adults with BMI between 25 and 29.99

Proportion of adults with BMI ≥ 30

Proportion of pregnant with anaemia (Hb <11 g/dl)

Nutrition Surveillance Indicators – Suggested Core


Nutrition Surveillance Indicators – Minimum Core

Children (<5 years of age) Measurements Required

Proportion of children underweight (weight for age below - 2SD) weight

Proportion of children severely underweight (weight for age below - 3SD) weight

Proportion of children wasted (weight for length/height below -2SD) weight and length/height

Proportion of children severely wasted (weight for length/height below -2SD) Weight and length/height

Proportion of children stunted (length/height for age below -2SD) Length/height

Proportion of children severely stunted (length/height for age below -3SD) Length/height

Proportion of children at risk of overweight (BMI for age or weight for length/ height above 1SD) Weight and length/height

Proportion of overweight children (BMI for age or weight for length/ height above 2SD) Weight and length/height

Proportion of obese children (BMI for age or weight for length/ height above 3SD) Weight and length/height

Percent of infants exclusively breastfed through 6 months of age Clinic records/survey

Percent of live births weighing less than 2,500 grams Hospital records

Proportion of children with anaemia (Hb <11 g/dl) Blood Test

Older children (5 – 19 years of age)

Proportion of underweight schoolchildren (weight for age (up to 10 years) below -2SD) weight

Proportion of severely underweight schoolchildren (weight for age (up to 10 years) below -3SD) weight

Proportion of children stunted (height for age below -2SD) height

Proportion of children severely stunted (height for age below -3SD) height

Proportion of overweight children (BMI for age or weight for height above 1SD) Weight and height

Proportion of obese children (BMI for age or weight for height above 2SD) Weight and height

Proportion of children with anaemia (Hb <11 g/dl) Blood Test

Adults and Pregnant women

Proportion of adults with BMI between 25 and 29.99 Weight and height

Proportion of adults with BMI ≥ 30 Weight and Height

Proportion of pregnant with anaemia (Hb <11 g/dl) Blood Test


• To know what these indicators mean for our population,and to compare with the rest of the world, we need to useinternational standards.

• The Standards currently used for nutritional status ofchildren 0-5 years are the 2006 WHO New GrowthStandards.

• Those for the 5-19 years are the WHO

2007 Reference Curves


1 year 2 years 3 years 4 years 5 years


• The new WHO Child Growth Standards are the result of anintensive study initiated by WHO in 1997 (The MulticentreGrowth Reference Study (MGRS). This study was acommunity-based, multi-country project conducted in Brazil,Ghana, India, Norway, Oman, and the United States ofAmerica.

• The study followed term babies from birth to 2 years of age,with frequent observations in the first weeks of life.

• Another group of children, age 18 to 71 months, weremeasured once, and data from the two samples werecombined to create the growth standards for birth to 5 yearsof age.

The new international standard for child growth


• The WHO Child Growth Standards go beyond the current references.

• They allow important growth measurements, such as body weight andlength/height of infants and children to be assessed against a standardoptimum value.

• Additionally there are now the development of Windows of Achievement forsix key motor development milestones

o sitting without support;

o standing with assistance;

o hands-and-knees crawling;

o walking with assistance;

o standing alone; and

o walking alone

that healthy children are expected to achieve during specified age rangesbetween 4 and 18 months will provide a unique link between physical growthand motor development.

How are the new WHO Child Growth Standards different from the old ones?


New standards for children 0-5 years:

• Weight-for-age

• Length/height-for-age

• Weight-for-length/height

• BMI-for-age

• Head circumference-for-age

• Arm circumference-for-age

• Triceps skinfold-for-age

• Subscapular skinfold-for-age


Interpreting the Plotted Points

• The curved lines printed onthe charts will help youinterpret the plotted pointsthat represents the childgrowth status.

• The line labelled “0” oneach chart represents themedian or the average

• The other curved lines are“z-score lines” whichrepresent distance from theaverage (standard deviation(SD) scores).


At risk of overweight

Overweight

Obese

Wasted

Severely Wasted

BMI for Age (Under 5 years)

Severely wasted: Below -3 (Z-score)Wasted: Below -2 (Z-score)Normal: At -2 through to +1 (Z-score)

At risk of Overweight : Above +1 (Z-score)Overweight: Above +2 (Z-score)Obese: Above +3 (Z-score)



Stunted

Severely

Stunted


Overweight

Obese

Severely Thin

Severely

ObeseBMI for Age (5-19 years)Overweight:Above +1 (Z-score)

ObeseAbove +2 (Z-score)


To assist countries the former CFNI and now continued by CARPHA workedwith member states to:

• revise their Child Clinic Records and Take Home Records in keeping withthe 2006 WHO Growth Standards

• Monitor the growth and development of children. The goal of growthmonitoring and promotion (GMP) in early childhood is to improve andmaintain the health and nutrition of young children. GMP involves the use ofinformation on the physical growth of children to counsel and guidemothers/fathers to make informed decisions on follow-up care.Supervision, including the periodic assessments of health workers’performance, and in-service training are important aspects of GMPprogrammes.

• They are needed to ensure that correct techniques of weighing and chartingare maintained and the quality of the counselling process is enhanced andsustained.

Nutrition Surveillance


Comparison

CDC 2000 and WHO 2006 Growth

Standards


CDC Reference• CDC 2000 Growth Reference curves

– 1970 – 1990 studies of US children

• No data from birth to 2 months

• Mixed feeding – 1/3rd breastfed – on average for 3months

• Cross- sectional data

• Same statistical approach as WHO


Ref:


Ref:

Preventing disease, promoting and protecting health31

Differences between the NCHS

1978 and the WHO 2006 growth

curves


GIRLS WEIGHT-FOR-AGE 0-11 m

0

1

2

3

4

5

6

7

8

9

10

0 2 4 6 8 10Age (m)

We

igh

t (k

g)

NCHS

WHO

median

-1 SD

-2 SD

-3 SD


Differences in the Prevalence of Underweight Case Study: Malawi (DHS 2000) Children 0-59 m

% children WAZ score <-

2 SDNCHS 1978 WHO 2006 Change

0-5 m 4.1 11.8 +7.7

6-11 m 22.4 21.2 -1.2

12-23 m 33.6 22.4 -11.2

24-35 m 29.0 21.5 -7.5

36-47 m 19.9 15.2 -4.7

48-59 m 19.4 16.3 -3.1

Total 0-59 m 23.3 18.6 -4.7


Food Surveillance Indicators

Energy availability/ caput/ day

Protein availability/ caput/ day

Fat availability/ caput/ day

Energy availability/ caput/ day

Protein availability/ caput/ day

Fat availability/ caput/ day

Amount (kg) of locally produced foods

The cost of consuming a well-balanced 2400 Cal diet/ day

Proportion of foods imported

Proportion of foods exported

Food Price Index

Suggested Core Indicators

Minimum Core Indicators


Other indicators As our systems become more efficient and otherinterventions are implemented we should be able todocument:

– % of population eating <5 servings of fruits and vegetablesa day

– % adults with low levels of physical activity

– % of children and adolescents with low levels of physicalactivity

– % population with dietary fat intake <30%

– % of people with dietary sodium chloride (sodium /saltintake0 <5g per day

– Population based percentages of overweight and obeseadults, children and adolescents


• For the FNSS to function effectively appropriatemanagerial and physical structures need to bestrengthened or put in place.

• Data entry should not be an end in itself.

• The information system should be adequately managed.



Major Considerations for Food and Nutrition Surveillance

Data related issues:

• The requirements and procedures for identifying and monitoring datacollection, collation and analysis should be specified.

Processing requirements:

• The requirements and procedures for reporting need to be detailed:

– how the report is to be generated;

– the frequency of reporting;

– the number of reports and for whom - ensuring reports are suitable tothe intended audience

• Technology issues – What is the capacity of the organization to handlenew technologies – computers, new analytic applications.

• Human resources – Determine personnel requirements for datacollection, data entry, data analysis, systems management, computerspecialists, personnel for equipment and other inputs. Education,experience, training, supervision and incentives all should be considered.


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Preventing disease Promoting and protecting healthcarpha.org/Portals/0/docs/MEETINGS/Epid_LabDir/Bocage_Food_and... · Preventing disease, promoting and protecting health Food and