Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in...
Transcript of Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in...
Zita Weise Prinzo Evidence and Programme Guidance Department of Nutrition for Health and Development WHO Geneva
Informal Consultation with Member States and UN agencies on
A proposed set of indicators for the Global Monitoring Framework for
Maternal, Infant and Young Child Nutrition
WHO/HQ, Geneva, 30 September – 1 October 2013
Reduce and maintain childhood
wasting to less than 5 %
Outline
• Background for target – Rationale
– Definition
• Logical framework joining the indicators
• Proposed outcome indicators – Strengths
– Limitations
– Data availability
• Proposed process indicators – Strengths
– Limitations
– Data availability
Background
• Wasting is defined as a low weight-for-height.
• Wasting or thinness is due to a recent and severe process of weight loss, often associated with insufficient food intake (nutrient and energy density), and disease.
• Typically, the prevalence of wasting in young children peeks in the second year of life.
Background
• 51 million children are wasted globally
• 17 million of these are severely wasted and at high risk of mortality
• Wasting prevalence in 2012 was almost 8% globally of these 3% were severely wasted
• 69% of all wasted children lived in Asia and 23% in Africa
• 71% of all severely wasted children lived in Asia and 28% in Africa
• 64 countries reported wasting rates > 5%
Rationale
• Where the prevalence of wasting is high there is a parallel increase in morbidity and mortality.
• Children who are severely wasted need urgent medical and special nutritional care.
• Children who are moderately wasted require increased intake of energy and essential nutrients and treatment of any associated medical conditions.
• Undernutrition is an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles.
Definition
Children aged < 5 years wasted (%):
Percentage of weight-for-height less than -2 standard deviations of
the WHO Child Growth Standards median among children aged 0 to
5 years
Wasting and stunting
Serial episodes of wasting will affect stunting prevalence • In 2/3 severely malnourished children, recovery of at least
85% WL required before resuming linear growth (Jamaica: Walker & Golden, 1988)
• Wasting (<-2 SD), highly variable WLZ, or negative changes in WLZ between 6-17 mo increase risk of linear growth retardation by age 18-24 mo (8 cohort studies, 4 countries: Richard et al, 2012)
Actions to address wasting
• Preventive interventions:
• Access to nutrient rich foods and to health care
• Improved nutrition and health knowledge and practices
• Promotion of exclusive breastfeeding and improved complementary feeding practices
• Improved water and sanitation systems and hygiene practices to protect against communicable diseases.
Actions to address wasting
• Appropriate treatment of children with severe acute malnutrition: • Community screening - early identification
• Treatment of infections
• Access to therapeutic foods
• Inpatient management (medical complications)
• Monitoring and follow-up.
• Appropriate treatment of children with moderate acute malnutrition: • Optimal use of locally available foods
• Where necessary specially formulated foods.
Agriculture and Food Systems • Food production and
processing •Availability of micronutrient-
rich foods • Food safety and quality
Inadequate practices • Infrequent feeding • Inadequate feeding
during and after illness • Thin food consistency • Feeding insufficient
quantities • Non-responsive feeding
Health and Healthcare • Access to healthcare • Qualified healthcare
providers • Availability of supplies
•Infrastructure •Health care systems and
policies
Education • Access to quality education
• Qualified teachers • Qualified health educators • Infrastructure (schools and
training institutions)
Food and water safety • Contaminated food and
water • Poor hygiene practices • Unsafe storage and preparation of foods
Concurrent problems & short-term consequences Long-term consequences
Poor quality foods • Poor micronutrient
quality • Low dietary diversity and intake of animal-
source foods • Anti-nutrient content • Low energy content of
complementary foods
Water, Sanitation and Environment
• Water and sanitation infrastructure and services
• Population density •Climate change •Urbanization
• Natural and manmade disasters
Political economy • Food prices and trade policy
• Marketing regulations • Political stability
• Poverty, income and wealth • Financial services
• Employment and livelihoods
Community and societal factors
Inadequate Complementary Feeding
Stunted Growth and Development
Health ↑Mortality
↑Morbidities
Developmental ↓Cognitive, motor,
and language development
Economic ↑Health
expenditures ↑Opportunity costs for care of sick child
Economic ↓ Work capacity
↓ Work productivity
Developmental ↓School
performance ↓ Learning capacity
Unachieved potential
Health ↓Adult stature ↑Obesity and associated co-
morbidities ↓ Reproductive
health
Infection
Clinical and subclinical infection
• Enteric infection: Diarrhoeal disease,
environmental enteropathy, helminths • Respiratory infections
• Malaria • Reduced appetite due to
infection • Inflammation
Household and family factors
Maternal factors • Poor nutrition during
pre-conception, pregnancy and lactation • Short maternal stature
• Infection • Adolescent pregnancy
• Mental health •IUGR and preterm birth • Short birth spacing • Hypertension
Inadequate practices • Delayed initiation • Non-exclusive breastfeeding
• Early cessation of breastfeeding
Context
Causes
Consequences
Society and Culture • Beliefs and norms
• Social support networks • Child caregivers (parental
and non-parental) • Women’s status
Home environment • Inadequate child
stimulation and activity • Poor care practices •Inadequate sanitation
and water supply • Food insecurity
• Inappropriate intra-household food allocation • Low caregiver education
Breastfeeding
PO1
IO1: malaria IO2: Diarrhea
PR1: Adequacy PR8: Diversity
PR2: Water PR3: Sanitation
PR4: ITN; PR5: ORS PR9: Immunization
PR6: dietary energy PR10: HH exp on food
Primary outcome indicator
• Prevalence of low weight-for-height in children <5 years of age defined as <-2 standard deviations of the WHO Child Growth Standards median • Rationale: To measure nutritional imbalance and malnutrition resulting in
wasting.
• Data availability: Most nutrition surveys, e.g. MICS, DHS, SMART and other national/sub-national surveys
• Limitations:
• Wasting is very responsive to infection and food availability. A child's weight relative to its height can drop quickly and also recover quickly with appropriate interventions
• Annual incidence would be more accurate estimate for this condition (however this data not available)
Intermediate outcome indicators (see stunting)
– Prevalence of malaria
• In malaria endemic areas, Global Health Observatory
– Incidence of diarrhea in under-fives
• Weak cross-sectional association with stunting , Global Health Observatory
Intermediate outcome indicators (optional)
• Prevalence of measles, rubella, pertussis, polio
• Rationale: To measure vaccine-preventable diseases, proxy also for
accessibility to health services
• Data availability: World Health Statistics (number of reported cases; immunization status)
• Limitations: No direct relationship between some of the diseases and wasting, e.g. polio
Process indicators (see stunting)
Complementary feeding
• % 6-23 month-olds receiving a minimum acceptable diet
• Mean dietary diversity score (minimum diversity for 6-23 month-olds)
Data availability
• From DHS and MICS, UNICEF
• For adults, FAO statistics (HH consumption surveys)
Process indicators (seestunting)
Household and family factors
• % population using an improved water source
• % population using improved sanitation facilities
• % population below minimum dietary energy consumption
• Proportion of average household expenditure on food of the bottom three deciles
Data availability • WHO Global Health Observatory (World Health Statistics)
• MICS (UNICEF)
• FAO HH Food consumption surveys
Process indicators (see stunting)
Process indicators
• Proportion of children with severe acute malnutrition having access to appropriate treatment including therapeutic foods. • Rationale: Effective treatment available to manage severe wasting
• Data availability: Records, special surveys
• Limitations:
• Information on severe acute malnutrition collected which includes children with oedema and/or MUAC less than 115 mm, no information on severe wasting alone
• Does not give Information on children with severe acute malnutrition who get treated over the total number of children who need treatment, and no information on actual recovery.
Process indicators (optional)
• Proportion of children born to HIV-positive women who are feeding in line with national guidelines on HIV and infant feeding
• Rationale: To prevent infants from being HIV+ and at greater risk of becoming wasted
• Data availability: Records, surveys
• Limitations: Any infant who is not fed adequately and appropriately is at risk of becoming wasted
Process indicators (optional to explore)
• Proportion of children with moderate acute malnutrition having access to appropriate supplementary foods.
• Rationale: In specific emergency and food insecure settings effective
treatment with supplementary foods can reduce prevalence of wasting
• Data availability: Records, special surveys
• Limitations:
• No clear information on children with moderate wasting who get treated over the total number of children who need treatment.
• Often MUAC is used as an indicator to screen children (moderate acute malnutrition)