SITUATION ANALYSIS - UNICEF ANALYSIS Approach to Nutrition Programming in the East Asia and Pacific...

SITUATION ANALYSIS

Approach to Nutrition Programming in the East Asia and Pacific Region2014 - 2025

Volume

2

Approach to Nutrition Programming in the East Asia and Pacific Region2014 - 2025

Volume

2

SITUATION ANALYSIS

© United Nations Children’s Fund August 2014

Permission to reproduce any part of this document is required.

Structure of the three volumes

The “Approach to Nutrition Programming for the East Asia – Pacific Region” comprises three volumes. Volume 1 articulates a set of packages of nutrition interventions for different contexts, and provides more specific guidance on how UNICEF can work with national governments to scale up effective nutrition interventions in multiple sectors. Volume 2 provides a detailed analysis of the situation in the region, and Volume 3 contains a detailed discussion of the causes and consequences of maternal and child under and over nutrition and the evidence base for the interventions proposed in the different packages.

The glossary, list of acronyms and full bibliography for all three volumes are found in Volume 1; each Volume also contains all the cited references as footnotes.

All data was current as of August 2014 and it is acknowledged that new data may become available in the future.

Acknowledgements

This three-volume Approach to Nutrition Programming was produced by the UNICEF EAPRO Nutrition team. France Begin, Regional Nutrition Advisor (to 2013) and Christiane Rudert, Regional Nutrition Advisor (from 2014) provided technical inputs, guidance and oversight. Karen Codling and Roger Shrimpton, Public Nutrition Solutions Ltd., prepared the drafts of the documents. The drafts were shared with all country offices to validate country specific information and get their inputs on proposed approaches. Special thanks is extended to all the country office colleagues who provided feedback, and also to the UNICEF EAPRO and New York colleagues who contributed their insights and suggestions.

Design and pre-press production was undertaken by Quo, Bangkok. www.quo-global.com

Photo credits

Cover: © UNICEF/NYHQ2013-0899/Ferguson Page 6: © UNICEF/NYHQ2012-1874/Noorani Page 26: © UNICEF/UKLA2014 - 1116/Lovell Page 37 : © UNICEF EAPRO/2015/ Dorothy Foote

United Nations Children’s Fund

UNICEF East Asia and Regional Office (EAPRO)

19 Phra Atit Road Bangkok 10200 Thailand

Website: www.unicef.org/eapro

E-mail: [email protected]

CONTENTS

Introduction

Child Nutritional Status in the Region – Anthropometry

Adult Nutritional Status in the Region – Anthropometry

Adolescent Nutrition

Birth Weight

The Burden of Malnutrition

Disparities in the Nutritional Situation

Nutritional Situation in the Region – Micronutrient Deficiencies

Status of Nutrition Practices and Programmes in the Region

Infant and young child feeding practices and programmes

Implementation of micronutrient programmes

Coverage of management of severe acute malnutrition

Coverage of health interventions

Water and sanitation access and hygiene practices

Dietary intake

Annex

Existing data on prevalence of other micronutrient deficiencies in the region

06

08

14

18

22

24

27

30

37

39

48

51

52

54

57

61

61

6 Approach to Nutrition Programming in the East Asia and Pacific Region, 2014 - 2025

INTRODUCTION

Strategic Approach and Implementation Guidance 7

In the East Asia and Pacific (EAP) region, despite economic growth, and achievements in health and

nutrition indicators, maternal and child malnutrition rates and burden remain high. Over 27 million

children are stunted in the EAP region, with one third of those children in China and another third

in Indonesia. Three of the top 10 countries with the greatest number of stunted children are in this

region. Eight countries in the region have a stunting prevalence above 30%, and if China is removed

from the dataset, the average regional prevalence is also over 30%. Just over 7 million children are

wasted, with 2 million of them severely wasted; the majority in Indonesia. It is of great concern that

the coverage of the treatment of severe acute malnutrition is extremely low (<1%) in the region, with

very few health facilities providing treatment and few trained staff. Anaemia is a moderate public

health problem for either women or children in 14 countries within the region and it is a severe

problem in five.

In five countries less than half of all babies start breastfeeding within an hour, and in 10 countries

more than half of all babies less than 6 months old are not exclusively breastfed. Data is lacking

on complementary feeding, despite its importance for child growth, but in countries with available

data only about 50% are considered to have a “minimum acceptable diet”. Further, these national

figures hide significant disparities; rural populations are more undernourished, for example stunting

prevalence is four times higher in rural areas in China than urban areas; and poorer communities are

more stunted, by 1.5-3 times.

While the major problem in the region remains undernutrition, a growing number of countries are starting to suffer from the “double burden of malnutrition” – the coexistence of under and over nutrition in the same communities, or even the same families.

In particular, the Pacific Island countries, Indonesia, China, Mongolia, Malaysia, and Thailand are

beginning to experience overnutrition in either women or children. Close to 11 million of this region’s

children are overweight. More than half of them are in China and a quarter are in Indonesia, however

Papua New Guinea, despite its small size, is home to 8% of the overweight and obese children in this

region. This phenomenon is caused by increased consumption of energy-dense, processed foods

in place of traditional cereals, fruits and vegetables and an increasingly sedentary lifestyle. It is also

occurring however when children who experienced growth faltering during the first 1,000 days of life

are subsequently exposed to more “obesity prone” environments later in life, and have a propensity

to lay down fat in adulthood due to their early life “programming”. The solution is thus the prevention

of foetal growth restriction and infant and young child growth faltering in the first two years, as well

as lifestyle changes and legislative measures focused on older children.

This second volume of the EAP regional approach to nutrition presents a detailed analysis of the

nutrition situation in the EAP countries as of July 2014: the status of nutrition indicators, the status of

the determinants of malnutrition and the status of nutrition programmes, based on the data that is

available at the time of writing.


As a region, East Asia has experienced a 71% reduction in stunting prevalence between 1990 and

2012; the largest reduction, by far, of all regions. However, it is recognized that a large proportion of

this reduction is due to the influence of China and its large decline from 30% in 1990 to 10% in 2011

(see Figure 1). If China is excluded from the EAP region average, stunting prevalence is estimated

to be above 30%, which is similar to the rates in South Asia and Africa and the rate in least

developed countries.

CHILD NUTRITIONAL STATUS IN THE REGION – ANTHROPOMETRY

Source: UNICEF-WHO-World Bank Joint Child Malnutrition Estimates, 2011 revision and State of the World’s Children 2014. NB. Prevalence estimates are calculated according to the WHO Child Growth Standards.

Figure 1: Global and regional stunting prevalence, 1990 and 2012

As suggested by the annual rates of reduction, nutrition is improving slowly in most countries of

the region. The above trend graph also shows the overall slow decline in stunting reduction for the

majority of countries (see Figure 2).

1990 2012

Perc

enta

ge

of

un

der

-5 c

hild

ren

(%

)

South

Asia

38% decline

19% decline

71% decline

42% decline

59% decline

50% decline

38% decline

0

10

20

30

40

50

60

70

Sub-Saharian

Africa

East Asia

and Pacific

Middle East

and North

Africa

CEE/CIS Latin America

and the

Caribbean

World


Ref: Created by EAPRO based on data in the UNICEF Childinfo database, MICS Thailand 2012, Timor-Leste NNS 20-13 and Philippines NNS 2011. http://data.unicef.org/index.php?section=topics&suptopicid=55

Figure 2: Trends in reductions in stunting

1 Black et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013.

2 WHO. Nutrition Landscape Information System (NLIS) Country Profile Indicators: Interpretation Guide. 2010.

50

60

70

0

10

20

30

40

Perc

enta

ge

of

un

der

5 c

hild

ren

(%

)

1987 1997 20071989 1999 20091991 2001 20111993 2003 2013

Indonesia

Cambodia

China

DPRK

Lao PDR

Malaysia

Mongolia

Myanmar

Thailand

Philippines

Timor-Leste

Viet Nam

1995 2005

Most countries have achieved annual reductions in stunting of less than one percentage point per

year; only Mongolia, Myanmar, Cambodia, Viet Nam, and Democratic People’s Republic of Korea have

achieved faster reductions. Even these rates compare unfavourably to the global average annual rate

of reduction of 2.1% between 1990 and 20111 (see Figure 3). Stunting rates are relatively stagnant in

countries such as Lao PDR, the Philippines, Malaysia, Thailand, and Timor-Leste.

Despite these improvements in stunting and some impressive achievements by some countries,

stunting rates remain >40%, categorized by WHO as “very high”, in Papua New Guinea (PNG), Lao

PDR and Timor-Leste, and 30-40%, categorized by WHO as “high prevalence”, in five other countries

in the region (the Philippines, Solomon Islands, Myanmar, Indonesia, and Cambodia). Other countries

like China, Tuvalu, Mongolia, Thailand, and Malaysia have a stunting prevalence considered as

“low prevalence”.2


Ref: UNICEF database reflecting national surveys in the year shown such as DHS, MICS, national nutrition surveys or living standards surveys. WHO categories of public health significance: WHO. Physical status: the use & interpretation of anthropometry. Report of a WHO Expert Committee. Technical Report Series No 854. Geneva, WHO 1995.

Figure 4: Stunting prevalence

Perc

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of

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der

five

ch

ildre

n (

%)

Singa

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(200

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EAPR

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oa (1

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)

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land

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aysia

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)

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atu

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i Dar

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nesia

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0)

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012)

0

10

20

30

40

50

60

70

46

≥ 40% WHO category: “very high prevalance”

30-39% WHO category: “high prevalence”

20-29% WHO category: “medium prevalence”

<20% WHO category: “low prevalence”

8 10 1012

15 16 1720

3 2426 28

33 34 35 3640

44 44

50

Ref: Calculated by EAPRO based on data in the UNICEF database. Period of comparison varies from 11 years in Timor Leste to 25 years in Thailand. Period of comparison for Brazil is 31 years. Start year was in the 1990s for all countries except Timor-Leste and end year varied between 2005 and 2012. Ref for global average is Lancet 2013, Paper 1.

Figure 3: Annual percentage points of decline in stunting

Perc

enta

ge

po

ints

Thai

land

China

Mal

aysia

Indo

nesia

Cambo

dia

Phili

ppin

es

Brazil

Globa

l ave

rage

Tim

or-L

este

Mon

golia

Viet

Nam

Lao

PDR

Mya

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DPRK

0.00

0.50

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1.50

2.00

2.50

3.00

0.33 0.340.46 0.50 0.52

0.750.83

0.97 1.01 1.03

1.34

2.1

2.28

2.57


3 The World Bank. Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. Washington DC. The World Bank. 2006.

4 http://www.scribd.com/doc/91495960/World-Development-Indicators-2012#outer_page_238

5 http://www.worldbank.org/en/news/2012/05/23/east-asia-and-pacific-economic-update-may-2012

6 http://www.scribd.com/doc/91495960/World-Development-Indicators-2012#outer_page_238

It is likely that some of the achievements in stunting reduction have been at least partially driven

by the high economic growth experienced, although it is known that economic growth does not

automatically improve nutrition and it often takes time.3 Average annual percentage growth of GDP

in East Asia and the Pacific was 8.5% in 1990-2000 and 9.4% in 2000-2010; these rates are significantly

higher than any other region.4 This strong economic development has contributed to the number of

people living in poverty being cut in half in the last decade.5 East Asia and the Pacific has experienced

the most rapid decline in poverty of all regions, driven largely by China, where extreme poverty fell

from 60% in 1990 to 13% in 2012.6 East Asia has also seen improvements in other key social indicators

such as safe water access, female school enrolment, and per capita caloric intakes. Caloric intakes

(measured by food availability because actual consumption data is not available) in the 1990s were

about 2,600 kcal/person, which is significantly higher than 1,800 kcal/person, which is the average

minimum energy requirement used by FAO.

Figure 5: Improvements in social indicators that may have contributed to improvements in nutrition

East Asia

MENA

South Asia

Sub-Saharan Africa

LAC

GDP or GNI per capita

Safe water access

0

1970s 1980s 1990s 2010

10

20

30

40

50

60

70

80

90

100

Per capita caloric intake

1970s 1980s 1990s

1500

2000

2500

3000

3500

Female secondary school enrolment

0

1970s 1980s 1990s 2010

10

20

30

40

50

60

70

80

0

1970s 1980s 1990s 2010

1000

2000

3000

4000

5000

6000

7000

8000

9000

Perc

ent

(%)

Kilo

calo

rie/

per

son


7 Young MF. And Martorell R. The public health challenge of early growth failure in India. EJCN 2013.

8 State of the World’s Children 2014.

Nevertheless, several countries in the region appear to have stunting levels in excess of what might

be expected based on their GDP, such as Malaysia, Thailand, the Philippines, and Indonesia. Those that

appear to have improved nutrition despite lower GDP are Myanmar, Viet Nam, and Mongolia.

Some countries also have a problem of wasting and overweight in young children. Wasting levels

in children 0-5 years are at a “serious” level in Timor-Leste, Indonesia, Malaysia, and Cambodia. It is

also important to recognize that with the shift to the new WHO child growth curves, it is now clear

that wasting peaks at a much earlier age (often in children less than 6 months old) than previously

thought (18-24 months). Thus data on wasting in children under five potentially masks a much

higher prevalence in the youngest children.7 The determinants of wasting, especially in the upper

middle income countries like Malaysia and Thailand, need to be investigated to appropriately target

prevention strategies.

Meanwhile, several countries are starting to experience high levels of child overweight, most notably

Mongolia, China, Brunei Darussalam, Tuvalu, Thailand, and Indonesia (see Figure 7). The regional

average of 5.3% overweight among children is still lower than some other UNICEF regions (e.g.

Central and Eastern Europe and the Commonwealth of Independent States with 15% prevalence and

the Middle East and North Africa with 11%).8 If action is not taken urgently, the number of overweight

children is likely to rise rapidly.

Figure 6: Comparison of stunting rate and GDP per capita (PPP) in the EAP region

Prevalence of stunting (moderate and severe) among under five year old children (WHO standards)

Ref: Prevalence of stunting: UNICEF database reflecting national surveys in the year shown. GDP per capita (PPP): World Bank , World Development Indicators Database, May 2012 Update (Data for 2010)

GDP per capita PPP in constant 2005 international dollars

< 20% : Low prevalence

20-29% : Medium prevalence

30-39% : High prevalence

=> 40% : Very high prevalence

Country Stunting (%) Year

Timor-Leste 58.1 2009/2010

Lao PDR 44.2 2011/2012

PNG 43.6 2005

Myanmar 35.1 2009/2010

Indonesia 35.6 2010

Cambodia 39.9 2010

Solomon Is. 32.8 2006/2007

Philippines 32.4 2008

Viet Nam 22.7 2010/2011

Vanuatu 26.3 2007

Mongolia 15.3 2010

Malaysia 16.6 2011

Thailand 16 2005-2006

China 9.9 2010

Perc

enta

ge

of

un

der

five

ch

ildre

n (

%)

0 2,000 4,000 6,000 8,000 10,000 12,000 14,0000

10

20

30

40

50

60


9 Shrimpton R. and Rokx C. The Double Burden of Malnutrition: a review of global evidence. HNP Discussion Paper. World Bank, June 2012.(in press).

10 Doak et al. Overweight and underweight co-exists within households in Brazil, China and Russia. J Nutr. 2000.

11 Oddo et al. Predictors of maternal and child double burden of malnutrition in rural Indonesia and Bangladesh. Am J Clin Nut. 2012.

12 Monteiro et al. Socio-economic status and obesity and adult populations of developing countries: a review. WHO Bulletin. 2004.

13 Popkin BM. The nutrition transition and obesity in the developing world. J Nutr. 2001.

14 Popkin BM. An overview on the nutrition transition and its health implications: the Bellagio meeting. Public Health Nutrition. 2002.


As Figure 7 illustrates, Indonesia has almost equal rates of child wasting and overweight. Thus, an

increasing number of countries in the region are suffering from the double burden of malnutrition.

The double burden of malnutrition (DBM) refers to the co-existence of over and under nutrition,

be it in the individual, the family, or household, or at the population level, across the life course.9

At the individual level, the most common form of DBM seems to be energy overnutrition and iron

deficiency. At a community level DBM has been reported in the same household with mothers being

overweight while their children are underweight. In China, for example, this has been recorded in 8%

of households.10 It has also been recorded in Indonesia (11%) and Bangladesh (4%).11

In developing countries, overweight and obesity are most commonly found in the wealthier quintiles.

However as national income increases, the burden of obesity tends to shift towards lower socio-

income groups.12 Moreover, overweight seems to be increasing faster than underweight decreases

in most low, middle and lower income countries13, the prevalence of overweight is increasing at 2-4

times the rate of the industrial world.14 The Lancet Nutrition Series 2013 reports that child overweight

has increased 54% between 1990 and 2011.15 Trend data on child overweight in the EAP region is

relatively limited; the data that is available does not show a clear pattern. Although overweight

prevalence has increased in Indonesia, the Philippines, Thailand, and Viet Nam, it has remained

stagnant in China (with significant fluctuations), Lao PDR, Mongolia, and Timor-Leste and it has

decreased in Cambodia and Myanmar. (data not shown)

Figure 7: Child wasting and overweight prevalence (sorted by wasting)

Ref: UNICEF database reflecting national surveys in the year shown such as DHS, MICS, national nutrition surveys or living standards surveys. WHO categories of public health significance: WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. Technical Report Series No 854. Geneva, WHO 1995.

Overweight Wasting

Wasting - WHO category:

>10% : “serious public health problem”

>15% : “critical public health problem”Pe

rcen

tag

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f u

nd

er 5

ch

ildre

n (

%)

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(200

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(201

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(201

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)

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dia

(201

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nesia

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)

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4

6

8

10

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1


ADULT NUTRITIONAL STATUS IN THE REGION – ANTHROPOMETRY

Adult nutritional status is measured by Body Mass Index (BMI), which is an index of weight-for-

height.16 International classifications of BMI rates have been established for adult underweight,

overweight, and obesity.17 However it has been recognized that BMI may not correspond to the same

degree of fatness in different populations due, in part, to different body proportions. The health risks

associated with increasing BMI are continuous and the interpretation of BMI grading in relation

to risk may differ for different populations. In particular, questions have been raised about the

appropriateness of international BMI classifications for Asian and Pacific populations. In 2002, WHO

convened an Expert Consultation on BMI in Asian populations,18 which concluded that the proportion

of Asian people with a high risk of type 2 diabetes and cardiovascular disease is substantial at BMIs

lower than the existing WHO cut-off point for overweight (≥ 25kg/m2). However, available data do

not necessarily indicate a clear BMI cut-off point for all Asians for overweight or obesity. The cut-off

point for observed risk varies from 22kg/m2 to 25kg/m2 in different Asian populations; for high risk it

varies from 26kg/m2 to 31kg/m2. No attempt was made therefore, to redefine cut-off points for each

population separately. The Consultation recommended that the current WHO BMI cut-off points for

Asia should be retained as the international classification. However the cut-off points of 23, 27.5, 32.5,

and 37.5 kg/m2 are recommended as points for public health action. Note that all data presented in

this report uses the global cut-offs.

Available BMI data for women in the region is shown in Figure 8 below. In general, a high proportion

of overweight and underweight women are not found in the same countries. Overweight in women is

predominantly a problem in the Pacific Islands and also appears to be developing in Mongolia, China,

Thailand, and Malaysia where more than 30% of women are either overweight or obese. Underweight

in women is the predominant problem in Cambodia, Viet Nam, and Timor-Leste. The global prevalence

of underweight in women is about 12%.19 The data shown below for Indonesia is actually from all adults

and not women only and obesity was categorized as BMI≥27 as opposed to ≥30 in other countries.

Unfortunately, trend data on adult BMI is limited for the region but overweight and obesity is believed

to be rising rapidly in Asia, as it is in the rest of the world. Although an OECD20 update reports that

the obesity epidemic has slowed down in several OECD countries in the past three years, it notes that

obesity rates doubled or tripled after 1980 such that in 19 of the 34 OECD countries, the majority of the

population is now overweight or obese. OECD projections estimate that more than two out of three

people will be overweight or obese in some OECD countries by 2020.21

16 Body Mass Index (BMI) is a simple index of weight-for-height that is commonly used to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of the height in metres (kg/m2).

17 BMI levels are categorized as follows: <18.5 = underweight, 18.-5-24.99 = normal, 25-29.99 = overweight, ≥ 30 obese.

18 WHO. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. A WHO Expert Consultation. Lancet 2004.


20 Organization for Economic Co-operation and Development. OECD countries are mainly high-income, developed countries.

21 OEDC. Obesity updated 2012. http://www.oecd.org/health/49716427.pdf


In Asia, limited data suggests rising adult overweight and obesity. For example data from the WHO

BMI database indicates that the proportion of adults with BMI>25 (overweight and obesity) increased

in China from 14.6% in 1995 to 18.9% in 200422 and Bell et al. reported in 2001 that in the last eight

years the proportion of Chinese men with BMI >25kg/m2 had tripled from 4-15% and the proportion in

women had doubled from 10-20%.23

Finucane et al. have used recent national health examination surveys to estimate trends in mean

national, regional, and global BMI levels.24 Figures 9 and 10 show the BMIs estimated by this analysis

for EAP countries between 1980 and 2008. The figures show that BMI levels have increased in all

countries of the region except for Brunei, where it is essentially unchanged, and Singapore and

DPRK where it appears to have fallen. On average, women’s BMI increased by 1.4kg/m2 in East Asian

countries whereas it increased by 6kg/m2 in Pacific Island countries. The highest increases in East Asia

were in Indonesia, Thailand, and Myanmar and the Cook Islands and Tonga in the Pacific. Women in

Nauru have the highest mean BMI in the world, while women in Bangladesh have the lowest. The key

point of this data however is that mean BMI is increasing in basically all countries of the region and

alarmingly so in the Pacific where rates are already extremely high. (NB. The BMI range of the X-axis

of the two figures is not the same.)

In low-income countries, obesity is more common in people of higher socio-economic status and

in those living in urban communities. It is often first apparent among middle-aged women. In more

affluent countries it is associated with lower socio-economic status, especially in women and

rural communities.25, 26

22 WHO global database on BMI http://apps.who.int/bmi/

23 Bell et al. Weight gain and its predictors in Chinese adults. Int J of Obesity and Related Metabolic Disorders. 2001.

24 Finucane et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 2011.

25 Seidell JC and Rissanen A. Prevalence of obesity in adults: The global epidemic. In: Bray GA and Bouchard C. Eds. Handbook of Obesity, 2004.

26 Pena M and Bacallao J, ed. Obesity and Poverty: A new public health challenge. Washington DC: Pan American Health Organization (PAHO), 2000.

Figure 8: BMI of adult women (sorted by BMI <18.5)

Ref: WHO Global Database on Body Mass Index plus additional DHS, MICS and national nutrition surveys in the years shown (shown with an asterix) NB. Age group varies; >19 years in Philippines and Fiji, 15-49 years in DHS surveys, not specified in data from WHO database. Alternative growth standards are available for children 5-19 years old - http://www.who.int/growthref/en/ although DHS surveys include girls aged 15-19 in the above data. Indonesia data is for all adults, and obesity cut-off is >27. Overweight and obesity prevalence is higher in women than men in Indonesia.

BMI <18.5

BMI 18.5-24.99

BMI 25-29.99

BMI ≥30

Perc

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0

10

20

30

40

50

60

70

80

90

100


Figure 9: Trends in age-standardized mean BMI in women by country in East Asia

Figure 10: Trends in age-standardized mean BMI in women by country in the Pacific

Ref: Finucane et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 2011 Calculated national mean BMIs extracted from Webtable 5.

Ref: Finucane et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 2011 Calculated national mean BMIs extracted from Webtable 5.

Mea

n B

MI

26

25

24

23

22

21

20

19

18

1980 1990 2000 2008

Korea

Brunei

Singapore

Mongolia

China

DPRK

Cambodia

Indonesia

Lao PDR

Malaysia

Myanmar

Philippines

Mea

n B

MI

34

32

30

28

26

24

22

20

1980 1990 2000 2008

Fiji

Cook Islands

Kiribati

Marshall Islands

Micronesia

Nauru

Palau

Papua New Guinea

Samoa

Solomon Islands

Tonga

Vanuatu


Data from Indonesia indicates that overweight and obesity is much more common in women and in

urban areas. It also rises progressively with increasing wealth quintile (see Figure 11).

Figure 11: Prevalence of adult overweight and obesity (BMI >25) in Indonesia, 2007

Ref: Indonesia Report on Results of the National Basic Health Research Survey (Riskesdas) 2007, National Institute of Health Research and Development, MOH.

% o

f p

op

ula

tio

n >

15 y

ears

18

5

10

15

20

25

30

19

1514 14

16

18

21

24 24 24

Total Q1 Q2

Economic quintile

Q3 Q4 Q5Urban Rural Male Female


ADOLESCENT NUTRITION

Adolescents make up 14% of the total population in the EAP region; varying from 28% in

Timor-Leste to 13% in China and 14% in Thailand.27 In some countries, adolescent girls are at

particular risk of malnutrition due to lower autonomy and access to resources. A review of available

data28 for countries in the region indicates that while in some countries adolescents have a relatively

high prevalence of underweight, in others, adolescents have a high prevalence of overweight and

obesity. When comparing the nutritional status of adolescents with older women it appears that while

adolescence appears to protect girls/women from overweight/obesity, and to some extent anaemia,

more adolescents than older women are underweight. It should be noted, however, that during

adolescence nutrition status should be assessed using the WHO growth reference pattern of BMI for

10-19 year olds. Unfortunately, almost every national survey that includes BMI estimations have used

adult (>19 years) cutoff points for measuring populations above 15 years of age, which has produced

a serious bias in BMI estimations for 15-19 year olds, with undernutrition being overestimated in this

group. Available data shows the highest rates of low BMI in girls aged 15-19 in Timor-Leste, where a

third of girls are underweight (see Figure 12, blue areas). The Philippines is the only country in the

region that has assessed BMI in children aged 10-19 using the standards for 10-19 year olds, and has

found a prevalence of 12.7% for low BMI.29

27 UNICEF. State of the World’s Children 2014: Table 11, Page 90.

28 MICS does not measure nutrition status among adolescents aged 10-19 and it also does not measure BMI among women aged over 15. DHS does not measure BMI among adolescents aged 10-19 using the WHO standards for that age group and it only measures BMI among women aged 15-49 in selected countries, using the standards for adults aged over 19 years.

29 Updating Survey FNRI 2011.

Figure 12: Nutritional status of adolescent girls (15-19 years)

Ref: National surveys such as DHS, MICS and national nutrition surveys in the years shown.

Perc

enta

ge

of

ado

lesc

ent

gir

ls 1

5-19

yea

rs

Solomon Is.

(2006/7)

Nauru

(2007)

Tuvalu

(2006)

PNG

(2005)

Vanuatu

(2007)

Mongolia

(2010)

Lao PDR

(2006)

Cambodia

(2010)

Timor-Leste

(2009/10)

02 2 3 4 4

18 1928

33

47

69

44

73

72

79 78

7065

51

29

53

23

24

3 4 2 2

10

20

30

40

50

60

70

80

90

100


Figure 13: BMI <18.5 (top chart) and ≥25 (lower chart) in reproductive age women by age group

Ref: Cambodia DHS 2010, Mongolia National Nutrition Survey 2010, Timor-Leste DHS 2009/10 and Papua New Guinea National Nutrition Survey 2005. NB. Age group is 15-49 years.

There is also a bias of using adult cutoff points in the measurement of overweight in 15-19 year olds,

in this case producing underestimations in overweight. The highest rates of overweight among girls

aged 15-19 are found in Tuvalu and Nauru, where over half of the girls are overweight (see Figure 12,

red areas). This may be underestimated. In Filipino girls aged 10-19 overweight prevalence was 6.7%,

using the correct standards.

Figure 13 compares the nutritional status of adolescent girls in some of these countries to that in

older women. In Cambodia, Mongolia and Timor adolescents are more likely than older women to

have a low BMI and have a much lower prevalence of overweight and obesity than older women. In

PNG however there is generally little difference in the nutritional status of adolescents compared to

older women.

15-19

20-29

30-39

40-49

Perc

enta

ge

of

rep

rod

uct

ive

age

wo

men

(%

)Pe

rcen

tag

e o

f re

pro

du

ctiv

e ag

e w

om

en (

%)

Cambodia (2010)

Cambodia (2010)

Age (years)

Mongolia (2010)

Mongolia (2010)

Timor-Leste (2010)

Timor-Leste (2009/10)

PNG (2010)

PNG (2005)

0

0

5

10

10

15

20

20

25

30

30

35

50

60

40

40

28

25

15

23

3

23

40

57

24

8 9

23

17

30

24

19

15 1518

33

28

2324

45

75

7

31


Figure 14: Anaemia in reproductive age women by age group

Figure 15: Adolescent girls (15-19 years) married/in a union (2002-2011) and % women (20-24 years) who gave birth before 18 years (2008-2012)

Ref: Cambodia DHS 2010, Mongolia National Nutrition Survey 2010, Timor-Leste DHS 2009/10 and Papua New Guinea National Nutrition Survey 2005. NB. Age group is 15-49 years.

Ref: State of the World’s Children 2014, based on data from MICS, DHS and other national surveys, 2005-2010. * Data on % of women who gave birth before 18 years is from prior to 2008.

Similarly, in all the countries shown, adolescents do not appear to be at higher risk of anaemia

(see Figure 14).

In many countries, a significant proportion of adolescent girls are married/in a union and/or start

childbearing before they are 18. Figure 15 shows available data on the proportion of adolescent girls

married/in a union and those who have started childbearing before they are 18 in the region. In view

of the risks associated with teenage pregnancy, for both the mother and the child, it is of concern that

more than 10% of women 20-24 have given birth before the age of 18 years in several Pacific Island

countries, Myanmar, Papua New guinea, and Lao PDR.

Adolescents married/in union (%)

% 20-24 year old gave birth before 18

0

5

10

15

20

25

30

5

2

8

3

8 710 10

1315

8 8 9 9

16

13

1514

1315

25

18

2121

18

22

13

677 7 75

3

Mon

golia

Cambo

dia

Tuva

lu*

Indo

nesia

Lao

PDR*

Mya

nmar

*

Viet

Nam

Thai

land

*

Mas

hall

Is*

Papu

a New

Gui

nea*

Sam

oa

Tim

or-L

este

Nauru

Solo

mon

Is*

Phili

ppin

es

Kiriba

ti

Vanu

atu

Mal

aysia

Singa

pore

(200

4)

Perc

enta

ge

of

rep

rod

uct

ive

age

wo

men

(%

)

15-19

20-29

30-39

40-49

Cambodia (2010)

Mongolia (2010)

Timor-Leste (2009/10)

Papua New Guinea (2005)

0

10

20

30

50

60

48

12

22

46

13

23

35 3537 37

42

15

20

43

1619

40 Years


Figure 16: Number of births to girls aged 15-19 in East Asia and Pacific countries

State of the World’s Children 2011: Adolescence: An Age of Opportunity. Calculated. Girls population aged 15-19 based on UN World Population Prospects data (2011).

While these percentages appear relatively low, they translate into high numbers in the larger

countries; more than half a million girls give birth before the age of 19 in Indonesia and the figure is

about a quarter of a million in the Philippines and China (see Figure 16).

Overall however, the majority of teenage girls in the region are not getting pregnant and the median

age at first birth is 20 years old and above.

This means that targeting adolescents or girls in secondary school is not on its own a sufficient

or appropriate strategy in many countries for reaching pre-pregnant women, a key target group

advocated by the Lancet Nutrition Series 2013. Additional strategies to reach pre-pregnant women

will be needed.

0

100,000

200,000

300,000

400,000

500,000

600,000 552,916

251,538

244,495

153,650

109,994

43,68041,360

37,36623,730

15,360

3,835

2,6031,890

1,2751,200

1,014 261 80

Indo

nesia

Cambo

dia

Phili

ppin

es

Lao

PDR Fiji

Tim

or-L

este

China

Mya

nmar

DPRK

Mon

golia

Viet

Nam

Papu

a New

Gui

nea

Sam

oa

Solo

mon

Isla

nds

Thai

land

Mal

aysia

Tong

a

Micr

ones

ia


BIRTH WEIGHT

Closely related to the nutrition of women is birth weight. In general the quality of birth weight data is

poor, because, in many countries, a large proportion of newborns are not weighed at birth and it is

not possible to weigh babies at birth in cross sectional surveys.

Babies that are weighed at birth tend to be better off (more likely to be born in health facilities, urban areas and of better-educated mothers), which can lead to an underestimation of low birth weight incidence.

Low birth weight data collected by national surveys is usually based on mothers’ recall or

examination of birth records or child health cards. In addition, low birth weight data seldom excludes

low birth weight due to prematurity, thus mixing up the two conditions. A recent publication has

calculated the different risks of being born small for gestational age (SGA) (the lowest tenth percentile

of the growth reference), preterm or both, illustrating the importance of differentiating small

birth size due to SGA as compared to prematurity. Being born SGA increased the risk of neonatal

mortality by two to five times, but being born preterm (<37 completed weeks of gestation) raised

the risk by 6 to 26 times. When children are born both SGA and preterm, neonatal mortality was

10-39 times higher than in otherwise normal neonates. The low birth weight category includes both

premature and growth-restricted infants. On the other hand it excludes babies heavier than 2,500g

who might nevertheless be SGA (below the tenth percentile on the growth reference). It is therefore

important to look beyond birth weight to identify future risks and develop appropriate prevention and

management strategies.30

30 Katz et al. Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled countries analysis. Lancet 2013.


Figure 17: Low birth weight prevalence

Ref: UNICEF database – most recent year available (1997-2011). Source is national surveys in the year shown such as DHS, MICS, national nutrition surveys or living standards surveys. Data from DHS has been reanalysed.

Globally the prevalence of low birth weight (LBW) is 15%; the East Asia and Pacific regional

prevalence is 6%, which is relatively low compared, for example, to 28% in South Asia,31 where

maternal nutrition is particularly poor.

Available data on LBW for the region is shown in Figure 17. As shown, LBW rates are reported to be

10% or above in almost half of all countries and rates are particularly high in several of the Pacific

Islands, the Philippines, and Lao PDR. Prior to acceptance in UNICEF’s global database, household

survey data on birth weight from MICS and DHS are adjusted to account for under-reporting and

misreporting of birth weights using published methods.32

The assumptions implicit in this adjustment are the following:

• Births with numerical birth weights reported are as likely to be low as those without reported

birth weights.

• Within the same country, the relationship between birth weight and the mother’s assessment of

infant size does not depend on whether the infant was weighed.

It should be noted, however, that adjusted rates may still underestimate the true magnitude of

the problem.

31 UNICEF. State of the World’s Children 2014.

32 Blank AK and Wardlaw T. Monitoring low birth weight: an evaluation of international estimates and an updated estimation procedure. WHO Bulletin. 2005.

Perc

enta

ge

of

new

bo

rns

(%)

0

5

10

0

3 3 34 5 5 5 6 6

8 8 9 9 910 10 10 10 11 11 11

12 13

15

18 18

21

27

15

20

25

30

Niue

(200

0)

Mya

nmar

(200

9/10

)

Kiriba

ti (1

998)

Sam

oa (2

009)

Mar

shal

l Is.

(200

7)

Tong

a (2

002)

Brune

i Dar

ussa

lam

(199

9)

Tuva

lu (2

007)

Tim

or-L

este

(200

3)

Nauru

(200

7)

China

(200

8)

Pala

u (1

998)

Viet

Nam

(201

0/11

)

Papu

a New

Gui

nea

(200

5)

Micr

ones

ia (2

000)

Kore

a (2

000)

Vanu

atu

(200

7)

Thai

land

(201

2)

Solo

mon

Is. (

2007

)

Cook I

s. (2

000)

Indo

nesia

(200

7)

DPRK (2

009)

Mal

aysia

(200

0-9)

Cambo

dia

(201

0)

Phili

ppin

es (2

008)

Mon

golia

(201

0)

Fiji

(200

4)

Singa

pore

(200

0)

Lao

PDR (2

011/

12)


THE BURDEN OF MALNUTRITION

It is important for an analysis of the nutrition situation to consider not only the prevalence of

malnutrition but also the numbers of children and women affected.33 Highlighting the numbers

affected in certain countries, especially large countries with lower prevalence of malnutrition, is an

important advocacy opportunity to ensure that address malnutrition remains on or is elevated on the

national agenda. It is also important to analyse the distribution of the burden within a country. The

largest numbers of stunted or wasted children may be living in large cities with lower prevalence, as

opposed to the remote rural areas with the highest prevalence. This has implications for the targeting

of programmes and the allocation of resources.

Although the regional prevalence of stunting is only 12%,34 when the numbers of stunted children

in each country in the region are added together, EAP region has an estimated total of 27.5 million

stunted children. A third of them are in China, although China has the lowest stunting prevalence in

the region. Another third are in Indonesia with a stunting prevalence of 36%. Compared to the rest

of the world, three of the countries in the list of top 10 countries with the largest numbers of stunted

children are in the EAP region (see Figure 18).

33 The Burden of Malnutrition calculations were made using the latest available figures in the UNICEF database. The information portrayed is just a raw estimation, based on population figures and averages and it is not backed up by UNICEF. Information will be adjusted accordingly, once official estimates are released by UNICEF.

34 State of the Worlds’ Children 2014.

Ref: Calculations by EAPRO using data from SOWC 2014.

Figure 18: Top 10 countries in the world by numbers of stunted children and where the stunted children of the EAP region live

0 10,000,000 20,000,000 30,000,000 40,000,000 50,000,000 60,000,000 70,000,000

Nigeria

Pakistan

China

Indonesia

Ethiopia

Bangladesh

DR Congo

Philippines

Tanzania 3,564,540

Viet Nam 6% Cambodia 2%Thailand 2%

Philippines 13%

Papua New Guinea 2%

Myanmar 6%

Malaysia 1%

Lao PDR 1%

Indonesia 32%

DPRK 2%

China 32%

3,572,800

5,027,130

6,180,340

6,201,800

8,863,920

8.893,400

9.678,240

10,690,920

57,878,880India


Thirteen percent of the region’s stunted children are in the Philippines, with 6% more in Viet Nam and

Myanmar; 2% are in Cambodia (see Figure 19).

Figure 19: Burden of malnutrition in the East Asia and Pacific region

Figure 20: Burden of poor infant and young child feeding in the East Asia and Pacific region (excluding China)



Thailand

Indonesia

DPRK

Papua New Guinea

Philippines

Myanmar

Mongolia

Viet Nam

Cambodia

Fiji

Solomon Is.

Lao PDR

Timor-Leste

VanuatuNot BF within 1 hour

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Non-EBF Un-timely CF

China

Myanmar

Indonesia

Cambodia

Malaysia

Philippines

Thailand

Lao PDR

Viet Nam

DPRK

Timor-Leste

Solomon Is.

Papua New Guinea

Mongolia

SingaporeStunting

1,000,000

9,000,000

8,000,000

7,000,000

6,000,000

5,000,000

4,000,000

3,000,000

2,000,000

Wasting Overweight

Nu

mb

er o

f p

eop

leN

um

ber

of

po

pu

lati

on


Co-existing with this high burden of undernutrition, almost 11 million children are overweight. Just over half of them are in China and a quarter are in Indonesia.

More than 17 million children do not start breastfeeding within the first hour and over 20 million do

not benefit from exclusive breastfeeding (EBF). Again the majority (about 65%) of them are in China,

because of its large size, but the numbers are large in other countries also. For example, 600,000 and

700,000 children are not exclusively breastfed in Thailand and Myanmar respectively. A relatively

large number of Lao children do not benefit from EBF compared to those in Cambodia although

similar numbers were not breastfed within an hour of birth in both countries. Figure 20 excludes

China in order to see the number of children affected in other countries more easily.

Considerably fewer children are disadvantaged by untimely complementary feeding; about 13

million in total, but relative to other countries, more children in Viet Nam appear to receive late

complementary feeding.

More than 41 million children are believed to be anaemic, and nearly 5 million pregnant women are

also anaemic.


DISPARITIES IN THE NUTRITIONAL SITUATION

The data quoted so far have all been national averages, which hide significant disparities within

countries. Stunting prevalence varies by wealth as shown in Figure 21. In most of the countries

shown, stunting prevalence is about 1.5 to 3 times higher in the poorest quintile compared to the

richest. However in Viet Nam it is more than six times higher, Nauru is five times higher and in

Mongolia it is almost four times higher. The country with the smallest disparity is the Solomon

Islands, followed by Indonesia. Globally, the difference is 2.47 times.35


Figure 21: Stunting prevalence by economic quintile in selected countries

National surveys in the year shown such as DHS, MICS, national nutrition surveys or living standards surveys.

The rural prevalence of stunting is universally higher than the urban prevalence. In China it is almost

four times higher, whereas in most other countries it is not more than twice as high. Moreover, little is

known about the urban poor, which is often a highly disadvantaged group hidden in urban statistics

(see Figure 22).

In contrast, there is very little difference in stunting rates of boys and girls, with boys slightly more

stunted than girls (see Figure 23).

Poorest Second Middle Fourth Richest

Perc

enta

ge

of

un

der

5 c

hild

ren

(%

)

Indonesia

(2010)

Cambodia

(2010)

Lao PDR

(2011/12)

Mongolia

(2010)

Myanmar

(2009/10)

Nauru

(2007)

Solomon Is.

(2007)

Thailand

(2005/6)

Viet Nam

(2010/11)

0

10

20

30

40

50

60

70

51

23

43

51

20

25

47

2119

4

34

22 21

9

41

67

24


Figure 22 Disparities in stunting prevalence: urban-rural

Ref: National surveys in the year shown such as DHS, MICS, national nutrition surveys or living standards surveys.

Figure 23 Disparities in stunting prevalence: male-female

Ref: National surveys in the year shown such as DHS, MICS, national nutrition surveys or living standards surveys.

Rural Urban

Perc

enta

ge

of

un

der

5 c

hild

ren

(%

)

0

10

20

30

40

50

60

111012

18

13

22

11

27

12

28

34

23

39 38

27

40

31

42

28 28 27

48 49

26

3

Tuva

lu (2

007)

Vanu

atu

(200

7)

China

(201

0)

Solo

mon

Is. (

2007

)

Cambo

dia

(201

0)

Thai

land

(201

2)

Tim

or-L

este

(201

3)

Papu

a New

Gui

nea

(200

5)

Mon

golia

(201

0)

Mya

nmar

(200

9/10

)

Lao

PDR (2

012)

Viet

Nam

(201

1)

Indo

nesia

(201

0)

Male Female

Perc

enta

ge

of

un

der

5 c

hild

ren

(%

)

0

10

20

30

40

50

60

1010

16 16 1814

2226

23 22

3026

32 3237

2933

38 3842

4643

47

53

40

47

3637

20

27

Tuva

lu (2

007)

Viet

Nam

(201

1)

Thai

land

(201

2)

Vanu

atu

(200

7)

Cambo

dia

(201

0)

Mon

golia

(201

0)

Solo

mon

Is. (

2007

)

Lao

PDR (2

012)

Phili

ppin

es (2

008)

Nauru

(200

8)

Mya

nmar

(200

9/10

)

Papu

a New

Gui

nea

(200

5)

Tim

or-L

este

(201

3)

DPRK (2

010)

Indo

nesia

(201

0)


There is also evidence that, in some countries at least, disparities have increased; in Lao PDR for

example, reductions in stunting prevalence between 2000 and 2006 were mainly in the wealthiest

quintile where stunting prevalence fell by 56%. In the poorest and second poorest quintiles it actually

increased by 7%36 (see Figure 24).

Figure 24: Disparities in the reduction in stunting in Lao PDR by wealth quintile

Ref: Lao PDR MICS 2000, 2006. UNICEF calculations.

36 Teerapong Praphotjanaporn, 2011. An analysis of chronic undernutrition. Report to UNICEF EAPRO.

Perc

ent

of

the

qu

inti

le s

tun

ted

-70.0

-50.0

-30.0

-10.0

10.0 7.1

Lowest MiddleSecond Fourth Highest

37.937.4

37.4

43.144.149.1

52.6

41.3

32.2

16.86.8

-13.2

-13.9

-55.7

30.0

50.0

70.0

% change 2000 2006


NUTRITIONAL SITUATION IN THE REGION – MICRONUTRIENT DEFICIENCIES

Anaemia/iron deficiency: Anaemia in young children and/or women is a severe public health problem

in about a third of all countries in the region and it is a moderate public health problem in basically all

countries of the region (see Figure 25).

Ref: WHO, Worldwide prevalence of anaemia 1993-2005, based on WHO’s Global Database on Anaemia, 2008, plus additional data from national surveys, such as DHS or national health or nutrition surveys in the year shown.

Figure 25: Anaemia prevalence (sorted by children <5)

Non pregnant Pregnant Under 5

>40%: severe public health problem

>20-40%: moderate public health problem

0

10

20

30

40

50

60

70

80

Micr

ones

ia

Viet

Nam

Cook I

sland

s

Papu

a New

Gui

nea

Tuva

lu

Niue

Sam

oa

Tong

a

Nauru

Singa

pore

Mar

shal

l Isla

nds

Thai

land

Lao

PDR

Tim

or-L

este

Pala

u

Kiriba

ti

Mon

golia

Cambo

dia

China

Mal

aysia

Phili

ppin

es Fiji

Solo

mon

Isla

nds

Mya

nmar

Brune

i Dar

ussa

lam

Indo

nesia

DPRK

Vanu

atu

Perc

ent


In children under five (see Figure 26) prevalence is generally highest in children under one year and

has generally halved by the time the child is two and the highest prevalence is almost universally

in children < 1 year. Mongolia is one the few countries with data on anaemia prevalence in children

under 6 months; already in this age group, it is highly prevalent.

This highlights the need to address anaemia in the youngest children.

Figure 26: Prevalence of anaemia in young children by age group

Ref: Lao PDR MICS 2000, 2006. UNICEF calculations.

Philippines 2008 Viet Nam 2009/2010

0

5

10

15

20

25

30

35

0

10

20

30

40

50

<121 2 3 4 5 12-23 24-35 36-47 48-59

Mongolia 2010

0

10

20

30

40

50

2-5 6-11 12-17 18-23 24-29 30-35 36-41 42-47 48-53 54-59

Months

Years

Months

Months

Cambodia 2010

0

20

40

60

80

100

6-8 9-11 12-17 18-23 24-35 36-47 48-59


In addition to the problem of the high prevalence of anaemia in both women and children, few

countries have achieved and maintained significant declines in anaemia, in either women or young

children (see Figures 27 and 28).

Analysis of global, regional, and national trends in haemoglobin concentration and anaemia

prevalence illustrates the continued high prevalence of anaemia and the very slow rate of

improvement in most regions.37 Mason et al suggest that the improvements that have been seen are

attributable to increased national income and more diversified diets, in particular meat consumption,

and reduced infectious disease, rather than supplementation programmes.38

37 Stevens et al. Global, regional and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet 2013.

38 Mason et al. Reduction of anaemia. Comment on Stevens et al. Lancet 2013.

Figure 27: Trends in anaemia in young children

Figure 28: Trends in anaemia in women

Ref: National surveys - Philippines: 1993, 1998, 2003, 2008; Cambodia: 2000, 2005, 2010; Timor-Leste: 2003, 2009/10; Mongolia: 1999, 2001, 2004, 2011; Viet Nam: 1995, 2000, 2006, 2009-11.

Ref: National surveys - Philippines: 1993, 1998, 2003, 2008; Cambodia: 2000, 2005, 2010; Timor-Leste: 2003, 2009/10; Viet Nam: 1995, 2000, 2006, 2009-11. RAW = reproductive age women.

Perc

enta

ge

of

un

der

5 c

hild

ren

(%

)

Year 1 Year 2 Year 3 Year 40

10

20

30

40

50

60

70

Perc

enta

ge

of

targ

et p

op

ula

tio

n (

%)

Year 1 Year 2 Year 3 Year 40

10

20

30

40

50

60

70


It is important to recognize that the above figures all refer to anaemia, which is caused by a variety of

conditions, including iron deficiency, and that some iron deficiency can exist without anaemia. Recent

analysis found that globally “the proportion of anaemia amenable to iron” was about 50% in non-

pregnant women and pregnant women and 42% in children and the iron-amenable share of anaemia

was largest where other causes of anaemia were fewer (e.g. >55% in pregnant women and children

in east and southeast Asia).39 However a limited amount of national data on iron deficiency (from

Indonesia, Mongolia and Lao PDR) suggests that a lower proportion of anaemia may be due to iron

deficiency. Conversely, in this region, it appears that in some countries, such as Thailand, a significant

proportion of anaemia may be due to haemoglobinopathies or thalassemia, which will not respond to

iron interventions.

Not many countries have data on iron deficiency (as opposed to anaemia) but the Indonesia

Riskesdas survey of 2007 revealed that 60% of anaemia in women and 70% in children was microcytic

anaemia, likely due to iron deficiency or thalassemia.40 Mongolia’s 4th National Nutrition Survey 2011

measured both anaemia (haemoglobin) and iron deficiency (serum ferritin) in 433 children. The results

are shown below. They indicate that about a fifth of children with anaemia were iron deficient and in

total 21.4% of children were iron deficient.41 Similar analysis from the Lao PDR National Maternal and

Child Nutrition Survey (MICS 3/NNS) 2006 found that 43% of non-pregnant women and 35% of young

children with anaemia had iron deficiency.42 In Lao PDR and Mongolia, therefore, iron deficiency was

the cause of less than half of the anaemia, contrary to the traditional assumption mentioned above.

It is assumed that the remaining anaemia is due to other causes such as vitamin B12 or folic acid

deficiency, haemoglobinopathies or thalassemia, anaemia of chronic diseases.

39 Stevens et al. Global, regional and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet 2013.

40 Microcytic anaemia is characterized by pale and small red blood cells. http://en.wikipedia.org/wiki/Microcytic_anemia

41 Children with infection (as indicated by CRP) were excluded from the analysis.

42 Knowles et al. Impact of inflammation on biomarkers of iron status in a cross-sectional survey of Lao women and children. Brit J Nutr (under review for publication).

Figure 29: Anaemia and iron deficiency children 2-59 months old in Mongolia

Ref: Public Health Institute, Nutrition Research Centre. Nutrition Status of Mongolian Population: Fourth National Nutrition Survey Report. Ulaanbaatar 2011.

59.5% Total population

Iron deficiency only 16.4%

Iron deficiency and anaemia 5%

Anaemia only 19.1%


43 http://web2.airmail.net/uthman/hemoglobinopathy/hemoglobinopathy.html

44 Panomai et al. Thalassemia and iron deficiency in a group of northeast Thai schoolchildren: relationship to the occurrence of anaemia. Eur J Paediatrics, 2010.

45 George et al. Genetic hemoglobin disorders, infection, and deficiencies of iron and vitamin A determine anaemia in young Cambodian children. JoN 2012.

46 Uddin et al. Pattern of thalassemia and other haemoglobinopathies: a cross-sectional study in Bangladesh. International Scholarly Research Network. 2012.

47 Sanchaisuriya et al. Thalassemia and hemoglobinopathies rather than iron deficiency are major causes of pregnancy-related anaemia in northeast Thailand. Blood Cells Mol Dis. 2006.

48 Pansuwan et al. Anaemia, iron deficiency, and thalassemia among adolescents in Northeast Thailand: Results from two independent surveys. Acta Haematol, 2011.

As noted, another potential cause of anaemia is haemoglobinopathies or thalassemias.

Haemoglobinopathies are genetic defects that result in the abnormal structure of the haemoglobin,

such as sickle cell anaemia, while thalassemias are conditions that result in the underproduction of

normal globin proteins. Some haemoglobinopathies and thalassemias are particularly prevalent in

Southeast Asia.The haemoglobinopathy haemoglobin E, in particular, has a high frequency amongst

Thai and Khmer groups, followed by Burmese and Malays, then Vietnamese and Bengalis. The gene

does not occur in ethnic Han Chinese or Japanese. Beta thalassemia is also very common amongst

Southeast Asians.43 A number of studies have tried to quantify the amount of anaemia caused by

these conditions, as opposed to iron deficiency. Thalassemia and haemoglobinopathies were found

to be the cause of 88% of anaemia in school children 10-11 years old in Northeast Thailand.44 The

results of two further studies also in Northeast Thailand are shown in Table 1 below. All three studies

concluded that thalassemia and haemoglobinopathies were more prevalent causes of anaemia in

this area than iron deficiency. A study of children 6-59 months in Cambodia found 60% of rural and

40% of urban children respectively to have an abnormal genetic haemoglobin disorder45 and 57.8% of

anaemic patients (aged 0-46+) in Bangladesh had either haemoglobinopathies or thalassemias.46 The

high prevalence of haemoglobinopathies and thalassemias demonstrated by these data and reported

in the literature will reduce the potential impact of iron interventions and complicate identification of

iron deficiency.

Table 1: Prevalences of thalassemia and iron deficiency in anaemic pregnant women and adolescents

in Thailand

Anaemic pregnant women47 Anaemic adolescents (15-17 years)48

Mukdahan Roi Et

Thalassemia 59.2 53.8 67.3

Iron deficiency (ID) 7.0 10.2 7.7

Combined thalassemia ID 25.4 30.8 9.6

No thalassemia or ID 8.5 5.2 15.4


Iodine deficiency: In contrast to anaemia rates in the region, urinary iodine excretion levels, as a

measure of iodine deficiency, have improved, such that the majority of countries in the region now

have adequate iodine status, at least in school age children at the national level. There is growing

awareness that it is important to also measure the iodine status of reproductive age women to

ensure that they are entering pregnancy with adequate iodine nutrition in order to protect foetal

development. At this time, a minority of countries has data on the iodine status of reproductive age or

pregnant women.

The improved iodine status is the result of increased coverage with iodized salt. Salt iodization is

mandatory in 14 out of the 29 countries in the EAP region. The regional average coverage is 91%,

the highest of all UNICEF regions.49 In most countries coverage with iodized salt has been steadily

increasing such that today four countries have coverage in excess of 90% and only four have

coverage of less than 50%. As Figure 30 shows however, not all salt is adequately iodized. There are

also several countries without data on this indicator. In some countries the proportion that is not

adequately iodized is significant e.g. in the Philippines, Indonesia, and Malaysia. In Lao PDR, and

Cambodia the survey results do not provide an assessment of adequacy of iodization. In recognition

that rapid test kits do not provide an accurate assessment of the adequacy of iodization, most of the

surveys now test at least a sub-sample of salt samples with a quantitative test such as titration or the

WYD checker machine.

Figure 30: Coverage with iodized salt

Ref: National surveys such as DHS, MICS, Living Standards, National Nutrition or IDD. Surveys assessing adequately of iodine with a quantitative methodology, such as titration, shown with an asterix *

49 It is not mandatory in Brunei, South Korea, and Singapore, most of the Pacific Islands or Viet Nam. In Malaysia it is currently only mandatory in two states and in Myanmar it is only mandatory for those licensed to produce iodized salt.

iodized (adequacy unknown)

adequately iodized

inadequately iodized

Perc

enta

ge

of

ho

use

ho

lds

(%)

Mal

aysia

(200

8)*

Viet

Nam

(201

0/11

)

Vanu

atu

(200

7)

Tim

or-L

este

(200

7)

Mon

golia

(201

0)*

Tuva

lu (2

007)

Lao

PDR (2

011/

12)

Indo

nesia

(201

2)*

DPRK (2

009)

Phili

ppin

es (2

008)

*

Mya

nmar

(201

1)Chi

na (2

012)

*

Papu

a New

Gui

nea

(200

5)*

Thai

land

(200

5/6)

Cambo

dia

(201

0)

0

10

20

30

40

50

60

70

80

90

100

6.8 22.9 34.4

24.5

47.2

45.1

59.9

25.3

83

46.2

75.1

96.692.5

82.779.5

0 0

21.4 9.89.5

23.5

7.715.8 17.3

55.8

6.1

45.8

17.92.2 7.4


Figure 31 illustrates the correlation between iodized salt coverage and median urinary iodine levels

of school aged children, and, if available, reproductive age women. It shows a positive association

between urinary iodine and salt coverage, as expected. However, in several countries, including

Indonesia, and the Philippines, the urinary iodine level appears higher than expected compared to

the salt coverage. Preliminary analysis suggests this is due to sub-national disparities in iodized salt

coverage and wide variation in the iodine content of salt within countries. In some countries it may

also reflect additional sources of iodine beyond household salt.

Vitamin A deficiency: Relatively few countries have data on vitamin A deficiency but throughout the

region, vitamin A deficiency in young children is believed to have declined due to high and sustained

coverage of vitamin A supplementation in young children (see data on programme coverage in

Table 2) and reduced incidence of infectious diseases. In the Philippines mandatory fortification of

wheat flour and vegetable oil as well as some voluntary fortification is believed to have contributed to

falls in vitamin A deficiency.50

Other micronutrient deficiencies: Little data exists on other micronutrient deficiencies in the region.

The results of various surveys suggests wide variation in several deficiencies but folate deficiency

seems to be a significant problem in some parts of China and the Philippines while zinc deficiency

poses a similar problem in Viet Nam. Vitamin D deficiency may also be a problem, especially in

northern hemisphere countries such as China and Mongolia. Myanmar is known to have a problem

of thiamine deficiency, and calcium deficiency may also be common. Available data on micronutrient

deficiencies is shown in the Annex.

Figure 31: Correlation between coverage with adequately iodized salt and medial urinary iodine excretion in selected countries

Ref: National surveys – Cambodia 2008; China 2011; Indonesia 2012; Lao PDR 2006; Malaysia 2008; Mongolia 2010; Myanmar 2006; Papua New Guinea 2005; Philippines 2008; Viet Nam 2005. UIE data is for school aged children unless otherwise indicated.

50 Nutrition Center of the Philippines. Final report. Review of the mandatory food fortification component of the Philippines Food Fortification Programme. Prepared for the National Nutrition Council. December 2012.

Perc

enta

ge

cove

rag

e ad

equ

atel

y io

diz

ed s

alt

y = 0.1766x + 35.846 R² = 0.10473

0

20

40

60

80

100

120

0

Viet Nam WRA

China WRA

Mongolia

Myanmar

PhilippinesMalaysia

China

Cambodia

Indonesia

PNG WRA

Lao PDR WRA

Viet Nam

50 100 150

Median urinary iodone ug/L

200 250 300


STATUS OF NUTRITION PRACTICES AND PROGRAMMES IN THE REGION


Global Coverage of Nutrition Specific Interventions

Despite the widespread consensus on which interventions are effective and the fact that most are feasible for widespread implementation even in resource-poor environments, the coverage of the majority of these interventions is extremely low.

As noted by Lutter et al in 2011: “Although effective health sector-based interventions for tackling

childhood undernutrition are known, intervention coverage data are available for only a small

proportion of them (5 of the 13 interventions identified in the Lancet 2008) and reveal mostly low

coverage.” This is due to a combination of low political commitment and attention to nutrition, and

weak programme design, implementation, and monitoring capacity for nutrition interventions,

in particular those that require regular community outreach, behaviour and social change, and

multisectoral collaboration.

Available coverage data by country of some of the effective nutrition-specific and nutrition sensitive

interventions is presented in this section.


Infant and young child feeding practices and programmes

Breastfeeding

The EAP region has either the lowest or second lowest regional rate for all the key infant and young

child feeding (IYCF) indicators.52 The regional rates are lower than the global average for all indicators.

Considering that 11.6% of global under-five mortality is attributable to sub-optimal breastfeeding,53

this is of significant concern. National breastfeeding initiation rates within one hour and EBF rates

for children 0-5 months old are shown in Figure 32. In about a third of all countries, for which data is

available, less than 50% of EAP newborns received breastmilk within an hour of birth. EBF rates are

even worse. Considering the large impact of optimal breastfeeding practices on preventing newborn

and child deaths, it is of significant concern that overall only 41% of EAP infants initiate breastfeeding

in the first hour after birth and only 30% are exclusively breastfed between 0 and 5 months.54

Figure 32: Key infant and young child feeding behaviours by region

Ref: State of the World’s Children Report 2014. Data are not available for the Middle East and North Africa, Latin America and Caribbean or CEE/CIS regions. Breastfeeding at 2 years does not include China.

52 In 2008, WHO published an updated set of indicators for assessing IYCF practices; countries in the region are still transitioning to these new indicators but to the extent possible, the new indicators have been used for presentation of the IYCF situation in the region. Ref: WHO. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. 2008.



East Asia and Pacific

West and Central Africa

World

East and Southern Africa

South Asia

0

10

20

30

40

50

60

70

80

90

Early initiation of breastfeeding

41

30

5145

60

52

72

61

35

25

45 4441

49

57

78

4239

60 58

Exclusive breastfeeding

Timely intro of complemntary feeding

Breastfeeding at 2 years


55 Conkle J for UNICEF Cambodia. An analysis of the determinants of exclusive breastfeeding in Cambodia. May 2007.

56 UNICEF. Programming Guide: Infant and Young Child Feeding. UNICEF, New York. May 2011.

Figure 33: Breastfeeding practices

Ref: UNICEF database. Source of data is national surveys such as DHS, MICS, national nutrition surveys. Date of survey is shown; if different surveys for the two indicators, first date is for early initiation and second is for EBF.

As shown in Figure 33, in 11 countries less than 50% of babies less than six months old are

exclusively breastfed, and in Thailand and Viet Nam the proportion is as low as 12% and 17%,

respectively. The poor situation in Thailand and Viet Nam stands in stark contrast to the situation

in neighbouring Cambodia. In 2000, the EBF rate in Cambodia was even lower than the current

rate in Thailand. Yet today it has increased to 73.5%, the highest in the region, due to intensive,

comprehensive efforts to increase it. Successful interventions that have contributed to this increase

include a consistent message not to give water that was disseminated through multiple channels

and one-on-one counselling.55 Timor-Leste has also significantly increased its EBF rate; from 31% in

2003 to 62% in 2013. Both Cambodia and Timor-Leste feature in a UNICEF compilation of countries

that have achieved more than 20 percentage point increases in EBF.56

Overall, rates of early initiation (babies fed within an hour of birth) are better; but the rates are

particularly low in Tuvalu and DPRK.

Early initiation EBF < 6months

Perc

enta

ge

of

infa

nts

(%

)

Thai

land

(201

2)

Phili

ppin

es (2

008)

Viet

Nam

(201

0-11

)

Tuva

lu (2

007)

Indo

nesia

(201

2)

Mya

nmar

(200

9-10

)

Fiji

(200

4)

Tim

or-L

este

(201

3)

China

(200

8)

Vanu

atu

(200

7)

DPRK (2

012/

2004

)

Mon

golia

(201

0)Nau

ru (2

007)

Cambo

dia

(201

0)

Solo

mon

Is. (

2007

)

Mas

hall

Is (2

007)

Lao

PDR (2

011-

12)

0

10

20

30

40

50

60

70

80

90

100

4640

76

41

73

54

15

57

72

39

49

93

18

7176

66

75

1217

2428

3134 35

40 40 40 42

62 65 66 6774 74


Complementary feeding

Complementary feeding behaviours are also poor. The percentage of children 6-8 months old who

have started receiving complementary food varies from a low of only 52% in Lao PDR to a high

of 91% in the Philippines. This indicator reflects late complementary feeding, which contributes

to child undernutrition because infants are not able to get enough calories and nutrients from

breastmilk alone after about 6 months. Even once complementary feeding has started, the limited

data available suggests that children may not receive complementary foods of sufficient dietary

diversity (4+ food groups) and/or be fed frequently enough. While both these practices appear to

be relatively good in the Philippines and Viet Nam for example, in DPRK only 49% of children aged

6-23 months receive complementary feeding with adequate frequency and only 27% with adequate

diversity. In all countries in the region, as in most other countries, dietary diversity is worse than

frequency. In Cambodia, whereas about two thirds of children get complementary foods enough

times, only one third get at least four food groups.

Figure 34: Complementary feeding behaviours

Ref: DHS, MICs and other national surveys in the years shown; data is for “all children” Timely introduction is for children 6-8 months while complementary feeding and meal frequency data is for children 6-23 months. Philippines data is from DHS, reanalysed for the new CF indicators by WHO. All other indicators have used the ‘new’ IYCF indicators for diversity and frequency.

Timely introduction Minimum frequency Minimum diversity

% o

f ch

ildre

n 6

-8 m

on

ths

and

6-2

3 m

on

ths

Viet Nam

(2010)

0

20

40

60

80

100

85

63

9197

8891

78

52

72

27

58

28

37

63

86

49

66

7975

81

31

43

Lao PDR

(2011/12)

DPRK(2012

& 2009)

Mongolia

(2010)

Indonesia

(2012)

Timor-Leste

(2013)

Cambodia

(2010)

Philippines

(2008)


More detailed data on these practices by wealth quintile, suggests that in Indonesia and Timor-Leste,

and to a lesser extent in Cambodia, the diversity of complementary food diets is closely associated

with family wealth. In Timor-Leste, in particular, diversity improves significantly with wealth such that

43% of children in the wealthiest quintile receive 4+ food groups whereas only about 20% of children

in the poorest quintile do.57 Frequency of feeding however is much less affected by wealth quintile. An

indicator of “minimum acceptable diet for breastfed children 6-23 months” has been developed which

is a composite of these two indicators plus whether or not the child is still breastfeeding or receiving

milk feeds. Only 28%, 42%, 47%, 49%, and 52% of children in Cambodia, Indonesia, Timor-Leste, the

Philippines, and Viet Nam are considered to have a minimum acceptable diet.58

Figure 35: Complementary feeding behaviours in Cambodia, Indonesia and Timor by wealth quintiles

DHS for Cambodia 2010, Indonesia 2012 and Timor-Leste 2009/10.

57 The new IYCF indicators specify that dietary diversity require the consumption of 4+ food groups. The Cambodia, Indonesia and Timor-Leste 2013 data used the new indicator.

58 The DHS of the Philippines, and Timor-Leste used the ‘old indicators’. The reported rates for minimum acceptable diet for the Philippines however has been recalculated by WHO using the new indicators. Ref: WHO. Indicators for assessing infant and young child feeding practices. Part 3: Country profiles. 2010.

Lowest

Middle

Highest

Second

Fourth

Cambodia 2010 Indonesia 2012 Timor-Leste 2009/2010

Per

cen

tag

e o

f ch

ildre

n 6

-23

mo

nth

s

4+ food groups Min times 4+ food groups Min times 3+ food groups Min times0

10

20

30

40

50

60

70

80

90

29

76

41

59

44

73

37

82

75 7370 70


Alive & Thrive (A&T) in Viet Nam undertook a baseline survey of IYCF practices in selected provinces

where A&T works. The baseline survey included 24 hour recall of complementary feeding diets and

found that in all provinces studied, children of 6-8 months and children of 9-11 months consumed

the recommended daily intake59 of energy, protein, calcium, vitamin A and vitamin C if they were

still breastfeeding. Only iron intakes were insufficient. Figure 36 shows the percentage of the

Recommended Dietary Allowance for each nutrient achieved and the contribution of breastmilk

compared to complementary food. The districts presented reflect the highest and lowest intakes.

This same survey found that 82.6% and 94.4% of children had the minimum dietary diversity

and minimum meal frequency respectively. This 24-hour recall data suggests that the quality of

complementary feeding may not be as poor a food group as data suggests.60

59 RDA established by the Vietnamese National Institute of Nutrition.

60 Alive & Thrive Viet Nam. Baseline Survey Report: Infant and young child feeding practices 2012.

Figure 36: % RDA from breastmilk and complementary food: two districts in Viet Nam

Ref: Alive and Thrive Viet Nam. Baseline Survey Report: Infant and Young Child Feeding Practices 2012.

Breastfed infants 6-8 months in Hanoi Breastfed infants 6-8 months in Thanh Hoa

Breastfed infants 9-11 months in Hanoi Breastfed infants 9-11 months in Thanh Hoa

Breastmilk Complementary Food

Energy (kcal)

Energy (kcal)

Energy (kcal)

Energy (kcal)

Protein (g)

Protein (g)

Protein (g)

Protein (g)

Iron (mg)

Iron (mg)

Iron (mg)

Iron (mg)

Calcium (mg)

Calcium (mg)

Calcium (mg)

Calcium (mg)

Vitamin A (mcg)

Vitamin A (mcg)

Vitamin A (mcg)

Vitamin A (mcg)

Vitamin C (mcg)

Vitamin C (mcg)

Vitamin C (mcg)

Vitamin C (mcg)

0% 0%

50% 50%

100% 100%

150% 150%

200% 200%

250% 250%

300%

0%

100%

200%

300%

400%

500%

600%

0%

100%

200%

300%

400%

500%

600%

300%


Bottle-feeding appears to be a problem is several countries in the region. Figure 37 below shows

available data on prevalence of bottle-feeding in children 0-5 months and 12-23 months old. It shows

that in several countries a significant proportion of even the youngest children are fed with a bottle,

which interferes with breastfeeding and increases the risk of child infection and disease because

of bacteria introduced through bottle-feeding and deficiencies in the formula or other liquids fed

through bottles.61 In Thailand about 73% of children are fed with a bottle, a third or more of children

0-5 months old in Indonesia, the Philippines, Viet Nam and Tuvalu are fed with a bottle and more than

a third of children 12-23 months old in six countries are fed with a bottle. In Thailand two out of three

children 0-5 months, and nearly three out of four children 12-23 months old are fed with a bottle. This

figure does not include data from countries such as China, and Malaysia where the use of bottles

might also be high.

In 2013 UNICEF launched the Nutrition Dashboard (NutriDash) online system to gather important

UNICEF and partner nutrition-related programme information across countries. Information available

for 2013 showed that the proportion of primary health care centres (PHC) with IYCF provided by trained

health workers in five EAP countries, Cambodia, Lao PDR, Mongolia, the Philippines and Timor-Leste,

was 89%, and that in Lao PDR, the Philippines and Timor-Leste the proportion of PHC with IYCF group

sessions was 95%.62 It is noted that limited routine data on the geographic scale and population

coverage of most IYCF interventions is available, as countries do not have systems to routinely

monitor these interventions.

61 http://www.infactcanada.ca/RisksofFormulaFeeding.pdf

62 UNICEF. NutriDash Global Data: IYCF Update. UNICEF June 2014.

Figure 37: Prevalence of bottle feeding

Ref: National surveys such as DHS, MICS and national nutrition surveys.

0-5 months 12-23 months

Perc

enta

ge

of

child

ren

un

der

2

Solo

mon

s (20

06/7

)

Kiriba

ti (2

009)

DPRK (2

009)

Mon

golia

(201

0)

Phili

ppin

es (2

008)

Tim

or-L

este

(200

9/10

)

Nauru

(200

7)

Viet

Nam

(201

0/11

)

Lao

PDR (2

011/

12)

Mar

shal

l Is.

(200

7)

Tuva

lu (2

007)

Cambo

dia

(201

0)

Indo

nesia

(201

2)

0

10

20

30

40

50

60

4 57

1114

16 18 19

29

41 42 42

21

11

3

18 18

25

38

16

36

41

52

35

42

21


63 Results of 2010-2011 assessment of key actions for comprehensive infant and young child feeding interventions in 65 Countries. (UNICEF, 2012). http://www.unicef.org/nutrition/files/IYCF_65_country_assessment_report_UNICEF.pdf

64 See Chapter 5 for a description of the evidence-based comprehensive package of interventions to improve breastfeeding and complementary feeding practices.

65 UNICEF. IYCF Programming Status. Results of 2010-2011 assessments of key actions for a comprehensive infant and young child feeding intervention in 65 countries. Yes response includes stand-alone policy and IYCF policy included in nutrition policy. na= no response.

66 ibid. na= no response or no information available.

67 UNICEF. National implementation of the International Code of Marketing of Breastmilk Substitutes (April 2011). Law = these countries have enacted legislation or other legal measures encompassing all or substantially all provisions of the International Code. Many/Few in law = many/few provisions of the International Code have been enacted in national law. Voluntary – in these countries, the government has adopted all, or nearly all the provisions of the International Code through non-binding measures. Some, voluntary – in these countries, the government has adopted some of the provisions through non-binding measures.

Earlier assessments of the policy environment and the scope of IYCF programmes63 give an indication

of the level of commitment and the comprehensiveness of the package of IYCF interventions.64

For example, Table 2 below summarizes data on country implementation of selected national level

IYCF actions. It illustrates a highly varied situation from country to country and also indicates that

information is missing on implementation of these key actions for several countries. It is also notable

that only three countries appear to have maternity legislation that meets the requirements of the

International Labour Organization of 14 weeks.

Country Country has an IYCF Policy65

Proportion of maternity facilities ever certified BFHI66

Status of Code Implementation67

Duration of paid maternity leave

Cambodia Yes 11% Many in law 12-13 weeks

China Yes NA Many in law 12-13 weeks

DPRK No NA No info 20 weeks

Fiji Yes 100% Law 12 weeks

Indonesia Yes 0% Many in law 12-13 weeks

Kiribati Some, voluntary

Lao PDR No 41% Many in law 12-13 weeks

Malaysia Voluntary < 12 weeks

Mongolia Yes NA Many in law > 17 weeks

Myanmar Yes NA Voluntary 12 weeks

Papua New Guinea Yes 15% Many in law 12 weeks

Philippines Yes 83% Law 8 weeks

Solomon Islands Being studied

Thailand NA 67% Voluntary 12-13 weeks

Timor-Leste Yes NA Voluntary 12-13 weeks

Vanuatu Yes 0% Some, voluntary

Viet Nam Yes 8% Many in law 24 weeks

Table 2: Country implementation of key national-level IYCF actions


IYCF in emergencies

Breastfeeding is a life-saving practice in emergencies, where lack of clean water and sanitation render

the use of breastmilk substitutes even more harmful. It provides an essential means of food security

and high quality nutrition for infants and protects them from the increased risks of disease and death

in emergency situations. Optimal IYCF is particularly difficult to achieve in emergency situations and

particularly if adequate IYCF policies are not already in place. If high coverage with optimal IYCF

practices (particularly breastfeeding) and capacity to support breastfeeding at health facility and

community levels is created before an emergency strikes, many problems can be avoided.

According to the 2010-2011 UNICEF IYCF assessment report69 only 46% of the EAP countries have

a national IYCF policy that includes infant feeding in emergencies. The assessment also shows

that 62% EAP countries reported having a national emergency preparedness plan, which includes

IYCF in emergencies and about 33% of EAP countries provide training for health providers or IYCF

counsellors on infant feeding in emergency.

Prevention of mother to child transmission and infant feeding guidelines

In 2010, WHO issued new guidelines on HIV and Infant Feeding70 that significantly changed the

implementation of interventions to prevent the transmission of HIV from mother-to-child. The new

guidelines took into account the high risk of mixed feeding, the risk of replacement feeding for infants

in some contexts and new evidence of significantly reduced transmission of HIV from mother to child

if the mother is receiving antiretroviral (ARV) interventions. Rather than counselling mothers on the

various risks and supporting them to make their own decision, the new Guidelines recommended

that national or subnational health authorities should decide whether health services will mainly

counsel and support mothers known to be infected with HIV to either breastfeed and receive ARV

interventions or avoid all breastfeeding. The 2010 HIV and Infant Feeding Guidelines have been

reinforced by the 2013 WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating

and Preventing HIV Infection.71

69 UNICEF. IYCF Programming Status. Results of 2010-2011 assessments of key actions for a comprehensive infant and young child feeding intervention in 65 countries.

70 WHO Guidelines on HIV and Infant Feeding 2010. http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/index.html

71 WHO Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Summary of key features and recommendations. June 2013.


The below table indicates the ARV programme option (Option A, B or C) and the infant feeding option

selected by countries in the region. Data from nine countries indicates that four have decided to

recommend EBF and ARVs (Cambodia, Indonesia, Myanmar, and Papua New Guinea), while three

countries recommend replacement feeding (Thailand, China, and Malaysia). Lao PDR and Viet Nam

recommend both.

72 Elimination of Parent-to-Child Transmission Women and Children Alive and Free from HIV and Syphilis. The Asia-Pacific Prevention of Parent-to-Child Transmission Task Force, Country Fact Sheets, 2010. http://www.eptctasiapacific.org

Country PMTCT and Infant feeding guidelines

Cambodia Option B (Maternal triple ARV prophylaxis) selected.

Exclusive breastfeeding (12m) recommended for exposed infants.

Indonesia PMTCT Guidelines have been revised (Option B+).

Exclusive breastfeeding is recommended for exposed infants, unless AFASS criteria met for formula feeding.

Thailand Option B (Maternal triple ARV, AZT/3TC/LPV/r) selected.

Formula feeding supported for 18 months.

DNA PCR testing of exposed infants at 2 and 4 months, HIV antibody test at 18 months.

China Option B (Maternal triple ARV prophylaxis) selected. Replacement feeding (infant formula) recommended and supported for HIV-exposed infants.

Plan to provide early infant diagnosis (EID) for exposed infants at 6 weeks and 3 months.

Lao PDR PMTCT and Infant Feeding Guidelines revised.

Option B (Maternal ARV prophylaxis) selected.

Currently recommend either EBF or exclusive formula feeding for exposed infants.

Myanmar PMTCT and Infant Feeding Guidelines under revision.

Option A (Maternal AZT + Infant NVP) selected.

EBF for six months recommended.

Papua New Guinea PMTCT and Infant Feeding Guidelines under revision.

Option B (Maternal triple ARV prophylaxis) selected.

EBF for six months followed by introduction of complementary feeding with breastfeeding.

Malaysia PMTCT and Infant Feeding Guidelines Revised in 2009.

All pregnant diagnosed with HIV to be initiated on ART - Option C. Exclusive replacement feeding for infants born to HIV positive mothers

Viet Nam MTCT and Infant Feeding Guidelines under revision.

Current guidelines: maternal AZT from 28 weeks, SD- NVP+ AZT/3TC tail for those presenting in labour.

Current infant feeding guidelines recommend either exclusive breastfeeding or exclusive formula feeding (supported by national programme) for exposed infants.

Table 3: PMTCT and infant feeding guidelines in EAP countries72


Implementation of micronutrient programmes

In 2008, the Lancet Nutrition Series identified effective nutrition interventions and recommended

their implementation at scale. They included several micronutrient interventions such as iron folate

or multiple micronutrient supplementation of pregnant women and salt iodization. The interventions

were considered to be both effective at improving nutrition and feasible for implementation on a

wide scale in developing countries. Table 3 summarizes coverage of these essential micronutrient

interventions in countries of the region.

As the table shows, apart from vitamin A supplementation of under-5 children, salt iodization, and

iron and folic acid supplementation of pregnant women in some countries coverage of the essential

micronutrient interventions is relatively low. It also indicates in which countries these effective

interventions are not national policy.

The coverage of “any tablets” of iron and folic acid supplementation for pregnant women is relatively

high in several countries, but as shown in the parenthesis, the coverage with the recommended dose

of more than 90 tablets during pregnancy is very low in most countries.

Zinc for diarrhoea is a relatively new intervention, which is still being scaled up. While it has already

been made policy in most countries, coverage remains low and data on coverage is lacking.

The deworming of young children, as opposed to school children, has been made policy by a minority

of countries, such as Cambodia and the Philippines. Iron and vitamin A fortification were also

recommended by the Lancet Nutrition Series 2008.

Currently however, only five countries have legislation for mandatory iron or vitamin A fortification

of any staple foods or condiments. Moreover, in three instances the programmes are not being

implemented; rice fortification in Papua New Guinea and the Philippines, and wheat flour in the

Solomon Islands.

Other micronutrient interventions recommended by the Lancet Nutrition Series 2008, such as

maternal deworming, malaria interventions and delayed cord clamping have even lower coverage

rates. Low coverage of these proven interventions, which are being implemented at scale in other

countries, reflects low political commitment and poor programme management.


Co

un

try

Un

der

5 c

hild

ren

inte

rven

tio

ns

(% c

over

age)

Pre

gn

ant

wo

men

inte

rven

tio

ns

(% c

over

age)

Co

mm

un

ity-

wid

e in

terv

enti

on

s

Vit

amin

A

sup

ple

men

tati

on

74

Zin

c fo

r d

iarr

ho

eaD

ewo

rmin

g75

Mu

lti m

icro

-n

utr

ien

t p

owd

ers76

Iro

n a

nd

folic

aci

d

sup

ple

men

tati

on

77

Mu

lti m

icro

-nu

trie

nt

sup

ple

men

tati

on

78

Ad

equ

atel

y io

dis

ed

salt

79 (%

cov

erag

e)Ir

on

/Vit

amin

A

fori

fica

tio

n80

Cam

bo

dia

982.

456

.4.

390

(57

)X

83*

X

Ch

ina

XX

X1.

181X

X99

X

Fiji

XX

Flo

ur

(iro

n)

Ind

on

esia

73X

X89

(33

)X

63Fl

ou

r (i

ron

)

Kir

ibat

i66

*34

X83

(7)

XX

X

Lao

PD

R47

X52

(25

)X

80X

Mal

aysi

aX

XX

96X

783X

Mar

shal

l Is

lan

ds

53*

22X

XX

X

Mo

ngo

lia54

0.2

X51

8447

(6)

1285

70X

Mya

nm

ar86

93.3

X84

X75

X

Tab

le 3

: PM

TC

T a

nd

Infa

nt

feed

ing

gu

idel

ines

in E

AP

co

un

trie

s73

73 R

efer

ence

: EA

PR

O o

r g

lob

al U

NIC

EF

dat

a u

nle

ss o

ther

wis

e st

ated

.

74 E

stim

ated

per

cen

tag

e o

f ch

ildre

n 6

-59

mo

nth

s re

ach

ed

wit

h 2

do

ses

of

vita

min

A s

up

ple

men

ts –

low

er p

erce

nta

ge

of

2 an

nu

al c

over

age

po

ints

in 2

011.

Hea

lth

sys

tem

ro

uti

ne

rep

ort

ing

dat

a co

mp

iled

by

UN

ICE

F. S

urv

ey d

ata

mar

ked

wit

h

an a

ster

ix –

per

cen

tag

e o

f ch

ildre

n 6

-59

mo

nth

s g

iven

vit

amin

A

sup

ple

men

tati

on

in la

st 6

mo

nth

s. R

ef. S

OW

C 2

014.

75 P

erce

nta

ge

child

ren

12-

59 m

on

ths

giv

en d

ewo

rmin

g m

edic

atio

n

in la

st 6

mo

nth

s. R

efer

ence

is u

sual

ly n

atio

nal

su

rvey

su

ch a

s D

HS

, M

ICS

or

nat

ion

al s

urv

ey.

76 U

NIC

EF.

Nu

triD

ash

Glo

bal

Dat

a: M

NP

Up

dat

e. U

NIC

EF

Jun

e 20

14.

Th

e p

erce

nta

ges

refl

ect

the

cove

rag

e o

f al

l ch

ildre

n in

th

e ta

rget

ed

age

gro

up

, rec

og

niz

ing

th

at m

any

cou

ntr

ies’

pro

gra

mm

es a

re p

ilots

o

r su

b-n

atio

nal

.

77 D

ata

refl

ect

con

sum

pti

on

of “

any

tab

lets

” d

uri

ng

pre

gn

ancy

. C

over

age

of “

90+

tab

lets

” is

sh

ow

n in

par

enth

eses

. So

urc

e is

u

sual

ly n

atio

nal

su

rvey

su

ch a

s D

HS

, MIC

S o

r n

utr

itio

n s

urv

ey.

78 D

ata

refl

ect c

on

sum

ptio

n o

f “an

y ta

ble

ts”

du

rin

g p

reg

nan

cy. S

ou

rce

is u

sual

ly n

atio

nal

su

rvey

s su

ch a

s D

HS

, MIC

S o

r n

utr

itio

n s

urv

ey.

79 P

rop

ort

ion

of

ho

use

ho

lds

con

sum

ing

ad

equ

atel

y io

dis

ed s

alt.

S

ou

rce

is u

sual

ly n

atio

nal

su

rvey

su

ch a

s D

HS

, MIC

S o

r n

utr

itio

n s

urv

ey. I

f ad

equ

acy

of

iod

izat

ion

is n

ot

kno

wn

, mar

ked

w

ith

an

ast

erix

.

80 D

ata

refl

ect

nat

ion

al m

and

ato

ry f

ort

ifica

tio

n o

f st

aple

fo

od

s o

r co

nd

imen

ts. N

on

-man

dat

ory

fo

rtifi

cati

on

is n

ot

incl

ud

ed.

81 S

ou

rce

is g

over

nm

ent

rep

ort

on

imp

lem

enta

tio

n o

f M

NP

s in

Ch

ina

- %

of

tota

l ch

ildre

n 6

-23

mo

nth

s in

Ch

ina

wh

o h

ave

rece

ived

Yin

g

Yan

g B

ao (

Ch

ines

e M

NP

s, in

clu

din

g p

rote

in p

ow

der

). P

rog

ram

me

is im

ple

men

ted

in 3

00 p

over

ty c

ou

nti

es; a

bo

ut

45%

of

child

ren

6-2

3 m

on

ths

hav

e re

ceiv

ed M

NP

s in

th

ese

cou

nti

es.

82 R

efer

ence

: Nat

ion

al N

utr

itio

n S

urv

ey 2

012.

Tab

le 6

.32.

26.

9%

of

pre

gn

ant

wo

men

to

ok

MN

S s

up

ple

men

ts f

or

at le

ast

6 m

on

ths

as r

eco

mm

end

ed.

83 S

alt

iod

isat

ion

is o

nly

cu

rren

tly

man

dat

ory

in t

wo

sta

tes

in

Mal

aysi

a. T

his

dat

a re

flec

ts n

atio

nal

cov

erag

e. C

over

age

wit

h

adeq

uat

ely

iod

ised

sal

t in

th

e m

and

ato

ry s

tate

s is

96.

5 an

d 5

7%.

84 S

ou

rce

is N

atio

nal

Nu

trit

ion

Su

rvey

201

0 –

per

cen

tag

e o

f ch

ildre

n

6-23

mo

nth

s w

ho

hav

e re

ceiv

ed M

NP

s in

last

6 m

on

ths.

On

ly 1

2.6%

o

f ch

ildre

n t

oo

k m

ore

th

an 6

0 sa

chet

s as

rec

om

men

ded

.

85 S

ou

rce

is N

atio

nal

Nu

trit

ion

Su

rvey

201

0. O

nly

1.1

% o

f w

om

en

too

k m

ore

th

an 9

0 ta

ble

ts a

s re

com

men

ded

.


Co

un

try

Un

der

5 c

hild

ren

inte

rven

tio

ns

(% c

over

age)

Pre

gn

ant

wo

men

inte

rven

tio

ns

(% c

over

age)

Co

mm

un

ity-

wid

e in

terv

enti

on

s

Vit

amin

A

sup

ple

men

tati

on

86

Zin

c fo

r d

iarr

ho

eaD

ewo

rmin

g87

Mu

lti m

icro

-n

utr

ien

t p

owd

ers88

Iro

n a

nd

folic

aci

d

sup

ple

men

tati

on

89

Mu

lti m

icro

-nu

trie

nt

sup

ple

men

tati

on

90

Ad

equ

atel

y io

dis

ed

salt

91 (%

cov

erag

e)Ir

on

/Vit

amin

A

fori

fica

tio

n92

Nau

ru10

.2X

39 (

2)X

XX

Pap

ua

New

G

uin

ea84

*73

X79

X92

.5R

ice

(iro

n)

Ph

ilip

pin

es90

1.5

3893

0.2

82 (

34)

X25

Flo

ur

(iro

n)

Oil

(vit

A)

Ric

e (i

ron

)

So

lom

on

Is

lan

ds

7*22

X50

(19

)X

Flo

ur

(iro

n)

Th

aila

nd

XX

XX

47X

Tim

or-

Lest

e59

5.8

351.

863

(16

)X

60X

Tuva

lu8.

9X

92 (

22)

X34

X

Van

uat

uX

X23

X

Vie

tnam

9498

951.

049

.513

.285

.39.

945

X

86 E

stim

ated

per

cen

tag

e o

f ch

ildre

n 6

-59

mo

nth

s re

ach

ed

wit

h 2

do

ses

of

vita

min

A s

up

ple

men

ts –

low

er p

erce

nta

ge

of

2 an

nu

al c

over

age

po

ints

in 2

011.

Hea

lth

sys

tem

ro

uti

ne

rep

ort

ing

dat

a co

mp

iled

by

UN

ICE

F. S

urv

ey d

ata

mar

ked

wit

h

an a

ster

ix –

per

cen

tag

e o

f ch

ildre

n 6

-59

mo

nth

s g

iven

vit

amin

A

sup

ple

men

tati

on

in la

st 6

mo

nth

s. R

ef. S

OW

C 2

014

87 P

erce

nta

ge

child

ren

12-

59 m

on

ths

giv

en d

ewo

rmin

g m

edic

atio

n

in la

st 6

mo

nth

s. R

efer

ence

is u

sual

ly n

atio

nal

su

rvey

su

ch a

s D

HS

, M

ICS

or

nat

ion

al s

urv

ey.

88 U

NIC

EF.

Nu

triD

ash

Glo

bal

Dat

a: M

NP

Up

dat

e. U

NIC

EF

Jun

e 20

14.

Th

e p

erce

nta

ges

refl

ect

the

cove

rag

e o

f al

l ch

ildre

n in

th

e ta

rget

ed

age

gro

up

, rec

og

niz

ing

th

at m

any

cou

ntr

ies’

pro

gra

mm

es a

re p

ilots

o

r su

b-n

atio

nal

.

89 D

ata

refl

ect

con

sum

pti

on

of “

any

tab

lets

” d

uri

ng

pre

gn

ancy

. C

over

age

of “

90+

tab

lets

” is

sh

ow

n in

par

enth

eses

. So

urc

e is

u

sual

ly n

atio

nal

su

rvey

su

ch a

s D

HS

, MIC

S o

r n

utr

itio

n s

urv

ey.

90 D

ata

refl

ect c

on

sum

ptio

n o

f “an

y ta

ble

ts”

du

rin

g p

reg

nan

cy. S

ou

rce

is u

sual

ly n

atio

nal

su

rvey

s su

ch a

s D

HS

, MIC

S o

r n

utr

itio

n s

urv

ey.

91 P

rop

ort

ion

of

ho

use

ho

lds

con

sum

ing

ad

equ

atel

y io

dis

ed s

alt.

S

ou

rce

is u

sual

ly n

atio

nal

su

rvey

su

ch a

s D

HS

, MIC

S o

r n

utr

itio

n s

urv

ey. I

f ad

equ

acy

of

iod

izat

ion

is n

ot

kno

wn

, mar

ked

w

ith

an

ast

erix

.

92 D

ata

refl

ect

nat

ion

al m

and

ato

ry f

ort

ifica

tio

n o

f st

aple

fo

od

s o

r co

nd

imen

ts. N

on

-man

dat

ory

fo

rtifi

cati

on

is n

ot

incl

ud

ed.

93 R

ef is

DH

S 2

008.

NN

S 2

008

reco

rds

“per

cen

tag

e ch

ildre

n 1

-5 y

ears

co

vere

d a

s 59

%

94 S

ou

rce

of

dat

a o

n d

ewo

rmin

g, M

NP

s, IF

A a

nd

MN

S f

or

pre

gn

ant

wo

men

is N

utr

itio

n S

urv

eilla

nce

Rep

ort

201

0. S

ou

rce

of

dat

a o

n

iod

ised

sal

t co

vera

ge

is M

ICs

2010

-201

1.

95 V

iet

Nam

pro

vid

es v

itam

in A

su

pp

lem

enta

tio

n f

or

a re

du

ced

ag

e g

rou

p. C

over

age

fig

ure

is r

epo

rted

as

targ

eted

.


The Lancet Nutrition Series 2008 and 2013 also recommended maternal supplementation with

multiple micronutrient supplements (MMNs), maternal calcium supplements and preventative

zinc supplementation. WHO also recommends multiple micronutrient powders (MNPs)96 for young

children. Few countries in the world are implementing these interventions on a national scale.

However, in this region Mongolia and China have started large-scale distribution of MNPs. The

programme is nationwide in Mongolia and targeted to children in 300 poor counties in selected

provinces in China. DPRK is planning to start nationwide MNP distribution and Viet Nam has

initiated a programme. Mongolia, DPRK, and Viet Nam have also started the implementation of

multiple micronutrients for pregnant women. In DPRK, multiple micronutrients have replaced the

iron and folate supplements. Coverage rates for these new programmes are shown in the table

above; full coverage has not been achieved for these new interventions yet, except for MNS in

DPRK. Periconceptual supplementation with folic acid, recommended by the Lancet Nutrition Series

2013, is not currently being implemented by any country in the region although DPRK is planning to

put into place weekly iron folate supplementation of reproductive age women which will effectively

reach periconceptual women with folic acid supplementation.

Coverage of management of severe acute malnutrition

The management of severe acute malnutrition (SAM) is critical for child survival and is a key

component of the scaling up framework for addressing undernutrition. UNICEF is a leading

organisation in the scaled-up implementation of community-based management of acute malnutrition

and provides technical support and capacity building for Ministries of Health and NGOs involved in

treating children with SAM. Globally, UNICEF remains the main procurer of ready-to-use therapeutic

food (RUTF), procuring approximately 80% of global needs, besides therapeutic milk (F-75, F-100) and

ReSoMal, which are essential for SAM treatment.

In 2012, UNICEF developed a web-based data collection and reporting system for SAM management

at national level, the system is known as NutriDash. The NutriDash system in 2013 found that

coverage of SAM treatment services remains very low. Globally, 60 countries reported providing SAM

treatment services in-country, whether in-patient, outpatient or both (although this is an increase

from 2009 when only 53 provided treatment).

96 WHO. Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age, 2011. http://www.who.int/nutrition/publications/micronutrients/guidelines/guideline_mnp_infants_children/en/

97 UNICEF, Coverage Monitoring Network, ACF International. The State of Global SAM Management Coverage 2012. New York August 2012.

98 UNICEF. NutriDash Global Data: SAM Management Update. UNICEF June 2014.

97, 98


Nine countries in EAP reported providing SAM treatment services in 2013 – Cambodia, Indonesia,

DPRK, Mongolia, Myanmar, Papua New Guinea, the Philippines, Timor-Leste and Viet Nam.99 The

estimated annual SAM caseload in those nine EAP countries in 2013 is an estimated of 4,259,247, yet

SAM treatment admissions in 2013 were only reported for six of these countries: Cambodia, DPRK,

Myanmar, the Philippines, Timor-Leste and Viet Nam; Indonesia, the country with the largest annual

burden of SAM, (2.9 million annual cases), did not report. In those six countries admissions totaled

33,677. That represents a 3% coverage of the estimated SAM cases for those countries. In EAP, DPRK

has the highest treatment coverage by indirect estimates (90%). In 2012 the coverage was 1.5%

among the 10 countries reporting.

Mean global geographical coverage, meaning the proportion of primary health care facilities in the

programme area that deliver SAM services compared to the total number of facilities is low at 14%, in

the countries reporting that achievement: Cambodia, DPRK, the Philippines, Timor-Leste and Viet Nam.

The top five barriers to access globally are lack of awareness about the programme, distance, lack of

awareness about malnutrition, carer busy/high opportunity costs, and previous rejection.

Coverage of health interventions

Coverage of health interventions is relatively high in most countries in the region. Moreover, in

countries where coverage has increased in recent years, pro-rich inequalities have declined.100

Regional coverage of measles immunization, skilled birth attendance, and at least one ANC visit

is above 90%. Regional rates for care during diarrhoea (diarrhoea treatment with oral rehydration

therapy and continued feeding) and contraceptive prevalence are still considerably lower. Within

the region, the more developed countries such as China and Thailand generally have higher

coverage, as do the socialist or previously socialist countries of DPRK, Mongolia and Viet Nam.

Lao PDR, Cambodia and Myanmar in the Mekong and Timor-Leste, the poorest country in the

region, continue to have low to moderate coverage and the middle-income countries of Indonesia

and the Philippines have moderate coverage. Care during diarrhoea in Thailand is an exception

to this general picture; despite being one of the more developed countries of the region, Thailand

has a relatively low rate of appropriate care during diarrhoea (52.7%). The picture is mixed in the

Pacific with very high coverage achieved for some health services, such as ANC and skilled birth

attendance at delivery, but low coverage for contraceptive prevalence rate. No data is available for

care during diarrhoea.

99 Laos is believed to be also providing SAM services but Laos did not respond to the 2013 data collection exercise.

100 Victora et al. How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Lancet 2012.



102 UNICEF. Pneumonia and diarrhoea: Tackling the deadliest diseases for the world’s poorest children. 2012.

Country Children 1 year-old

immunized against measles

% U5 with diarrhoea

receiving OR and feeding102

Contraceptive prevalence rate

Antenatal care coverage for at least one visit

Births attended by

skilled health personnel

Cambodia 93 48 51 89 71

China 99 - 85 94 100

DPRK 99 67 69 100 100

Indonesia 80 54 77 97 96

Lao PDR 72 49 50 54 42

Mongolia 99 56 55 99 99

Myanmar 84 50 46 83 71

Papua New Guinea 67 - 32 79 53

Philippines 85 60 49 91 62

Thailand 98 46 80 99 100

Timor-Leste 62 63 22 84 29

Viet Nam 96 65 78 94 93

Cook Islands 97 - 29 100 100

Fiji 99 - 32 100 100

Kiribati 91 - 22 88 80

Solomon Islands 85 - 35 74 86

EAP 94 56 64 93 92

Key to colours >90% >60% >70% 100% >70%

80-90% 50-60% 50-70% 80-100% 50-70%

>80% <50% <50% <80% <50%

Table 5: Coverage of health services101


Water and sanitation access and hygiene practices

Water and sanitation are important for nutrition for many reasons, including access to clean drinking

water, having access to water for hand washing and hygiene practices and safe disposal of faeces.

Improved drinking water and improved sanitation coverage in the region are relatively high at 91%

and 67% respectively.103

103 UNICEF. State of the World’s Children 2014. NB. Reference for regional data is SOWC 2014 whereas data for country situation is from the WHO/UNICEF JMP report 2014 Update.

However the regional averages hides considerable disparities – between countries and within

countries, such as between rural and urban areas.

Sanitation coverage, particularly in rural areas, remains low in several countries. In Papua New

Guinea, only 19% of households use improved sanitation facilities (see Figure 39). In addition, open

defecation is prevalent in the region; an estimated 100 million people in the region still practice

open defecation, with three countries (Indonesia – 63 million, China – 14 million and Cambodia – 8.6

million) among the 12 countries in the world with the largest populations practicing open defecation.

In Cambodia and the Solomon Islands around 55% of the population practices open defecation.

Figure 38: Use of clean drinking water source

Ref: WHO & UNICEF. Progress on Sanitation and Drinking-Water: JMP 2013 Update. NB. Piped on premises is considered an “improved” drinking water source. Surface water is considered an “unimproved” water source.

Improved Unimproved

Perc

enta

ge

of

nat

ion

al p

op

ula

tio

n

Papu

a New

Gui

nea

Kiriba

ti

Tim

or-L

este

Cambo

dia

Lao

PDR

Solo

mon

Is.

Mon

golia

Indo

nesia

Mya

nmar

Micr

ones

iaVa

nuat

uPh

ilipp

ines

China

Mar

shal

l Is.

Viet

Nam

Pala

uTh

aila

ndNau

ru Fiji

Tuva

luDPR

KSa

moa

Niue

Tong

aM

alay

sia

Cook I

sland

s

0%

10%

40

67 71 71 7281 85 85 86 89 91 92 92 95 95 95 96 96 96 98 98 99 99 99 100 100

20%

30%

40%

50%

60%

70%

80%

90%

100%


Figure 39: Use of sanitation facilities

Ref: WHO & UNICEF. Progress on Sanitation and Drinking-Water: JMP 2014 Update. NB. Shared and Open defecation are considered forms of “unimproved” sanitation facilities.

DefecationOpen Unimproved

Perc

enta

ge

of

nat

ion

al p

op

ula

tio

n

Papu

a New

Gui

nea

Solo

mon

Is.

Cambo

dia

Tim

or-L

este

Kiriba

tiM

ongo

liaM

icron

esia

Vanu

atu

Indo

nesia

Lao

PDR

China

Viet

Nam

Mya

nmar

DPRK

Nauru

Tuva

lu

Sam

oaTo

kela

u

Tong

a

Mal

aysia

Cook I

sland

sNiu

ePa

lau

Singa

pore

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Phili

ppin

esM

arsh

all I

s. Fiji

Thai

land

1929

37 39 40

56 57 58 5965 65 65 66

74 75 76 7782 83 87 91 92 93 96 97 100 100 100


Figure 40 shows urban-rural disparities in coverage with improved sanitation. In Indonesia, Kiribati,

Lao PDR, Mongolia, and Papua New Guinea less than 50% of the rural population have access to

improved sanitation.

Figure 40: Use of improved sanitation: urban-rural range

Ref: A Snapshot of Sanitation and Hygiene in East Asia and the Pacific – 2012 Update. NB. In Thailand, urban coverage at 95% is slightly lower than rural coverage at 96%.

Urban %

National %

Rural %

73 74

86

73

89

64

73

8379

94

76

96 96

31

64

80

54

63

5147

7674

76

66

96 96

20

Cambodia China DPR Korea Indonesia Lao PDR Malaysia Mongolia Myanmar Philippines Thailand Timor- Leste

Viet Nam Pacific sub region

56

71

39

50

29

37

73 69 68

57

95


Figure 41 also shows how the disparities continue at country level between rural and urban areas and

the rich and the poor.

Very limited data is available on hand washing access and practices although standardized indicators

for hand washing with soap are now being added to DHS and MICS surveys. In Cambodia, Mongolia,

and Viet Nam, 50.7%, 92.1%, and 86.6% of households respectively have a place with water and soap

for hand washing. Data is not available from other countries. The indicators measure (i) a place for

hand washing and (ii) the availability of water and soap. In Mongolia the place for handwashing was

the primary limiting factor whereas in Viet Nam the availability of water and soap was the greater

constraint. Data is not available for other countries.

Figure 41: Disparities in sanitation coverage

Ref: Joint Monitoring Programme Progress on Drinking Water and Sanitation 2012 and Philippines DHS 2008.

63 World

98 Samoa

96 Malaysia

93 Tokelu

64 China

57 Vanuatu

51 Mongolia

47 Timor-Leste

44 Papua New

Guinea

31 Cambodia

67 East Asia

& the Pacific

74 Philippines

79 Urban

100 Richest

20% Urban

100 Richest

20% Rural

75 Poorest

20% Urban

39 Poorest

20% Rural

69 Rural

85 CEE/CIS

38 South Asia

30 Sub-Saharan

Africa


Figure 42: Percentage of households with a place and water and soap for handwashing

Ref: Viet Nam: MICS 2010/11; Cambodia: DHS 2010; Mongolia: MICS 2010.

Poorest Second Urban RuralThird Fourth Richest

Perc

enta

ge

of

ho

use

ho

lds

Viet Nam Cambodia Mongolia

120

68

8388 91

95

30

10

48

70

86

96

4146

55

85

100

80

60

40

20

120

100

80

60

40

20

Viet Nam Cambodia Mongolia

91

82 83

44

77

38


Figure 43: Dietary energy supply (food available for consumption) from cereals and other foods by country, 2011

Ref: FAOSTAT FBS 2014. ‘Other foods’ include sugars and syrups, vegetable oils, fruits and vegetables, meat and milk, fish and fisheries products, animal fats and pulses.

Dietary intake

Figures 43 and 44 provide basic information on food availability in countries in the region (as most

countries do not have data on food consumption). The first indicates that food availability varies

from about 2,000 kilocalories per person to just over 3,000 kilocalories per person in the region with

the lowest food availability in Timor Leste and the highest in Brunei. This compares to estimated

human energy requirements of 1,750-3,400 kilocalories for women aged 30-60 years and 2,100-4,200

for men of the same age.104 The figure basically indicates that at a national level, all countries in the

region have adequate food available to meet estimated human energy requirements for men and

women aged 30-60. The same figure also indicates the proportion of the total food availability that

comes from cereals. While the average for the region is 49%, several of the Pacific Islands appear to

obtain a relatively small proportion of their calories from cereals and Timor-Leste, DPRK, Lao PDR,

and Cambodia all receive more than 60% of their calories from cereals. This reflects the lower level

of income in the second group of countries and would suggest a lower quality diet. In general, as

income rises, the proportion of calories from cereals declines.

104 FAO/WHO/UNU Expert Consultation, Rome 2001. Human energy requirements. FAO Food and Nutrition Technical Report Series. 2001.

Cereals Other

Kilo

calo

ries

per

per

son

per

day

Tim

or-L

este

DPRK

Lao

PDR

Cambo

dia

Mon

golia

Solo

mon

IsM

yanm

arPh

ilipp

ines

Viet

Nam

Indo

nesia

Thai

land

Sam

oaBru

nei D

arus

sala

mKiri

bati

Vanu

atu

China

0

500

1000

1500

2000

2500

3000

3500

Mal

aysia Fi

ji


Figure 44: Dietary energy supply (food available for consumption) by country in 1990, 2000 and 2011

Ref: FAOSTAT 2014 Food Balance Sheets 2011.

The second figure looks at trends in food availability over time. Most counties have experienced a 10-

15% increase in food availability between 1990 and 2011. However, food availability increased by more

than 20% in Cambodia, Myanmar, Viet Nam and Thailand. Food availability has decreased by 12%

in DPRK.K

iloca

lori

es p

er p

erso

n p

er d

ay

1990 2000 2011

Tim

or-L

este

DPRK

Lao

PDR

Cambo

dia

Solo

mon

Is.

Mya

nmar

Phili

ppin

esVi

et N

amIn

done

siaTh

aila

nd

Sam

oaBru

nei D

arus

sala

mKiri

bati

Vanu

atu

China

0

500

1000

1500

2000

2500

3000

3500

Mal

aysia Fi

ji

Mon

golia


Existing data on prevalence of other micronutrient deficiencies in the region

Iron Deficiency

Vitamin A Deficiency

Folate Deficiency

B 6 Deficiency

Zinc Deficiency

Vitamin D Deficiency

China: children 3-12 years

9.3% 41.3%

China pregnant women: High NTD prevalence area

50%

China pregnant women: Low NTD prevalence area

6%

Philippines – National Capital Region (13-45 years)

59.8% 62.8%

Philippines young children: 6 mths to <5 years

15.2% 21.6%

Philippines adolescents: 13-19 years

20.6%

Philippines: pregnant women

9.5% 21.5%

Philippines: lactating women

6.4%

PNG: Children 6-59 months

15.7%

PNG: Non pregnant women 15-45 years

0.7%

ANNEX


References:China: Ren et al. Comparison of blood folate levels among pregnant Chinese women in areas with high and low prevalence of NTDs. PHN 2007 and Yang X. National Institute of Nutrition and Food Safety.

Philippines: National Nutrition Survey 2008.

PNG: National Nutrition Survey 2005.

Mongolia: Fourth National Nutrition Survey 2011. Vitamin D deficiency = 25[OH]D<18nmol/l

Fiji: 2010 Impact study of iron fortified foods.

Indonesia: Sanjaja et al. Food consumption and nutritional and biochemical status of 0.5-12 year-old Indonesian children: the SEANUTS study. British Journal of Nutrition 2013.

Viet Nam: Le Nguyen et al. Double burden of undernutrition and overnutrition in Viet Nam in 2011: results of the SEANUTS study in 0.5-11 year old children. British Journal of Nutrition 2013.

Malaysia: Poh et al. Nutritional status and dietary intakes of children aged 6 months to 12 years: findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia). British Journal of Nutrition 2013.

Thailand: Rojroongwasinkul et al. SEANUTS: the nutritional status and dietary intakes of 0.5-12 year old Thai children. British Journal of Nutrition 2013.

Iron Deficiency

Vitamin A Deficiency

Folate Deficiency

B 6 Deficiency

Zinc Deficiency

Vitamin D Deficiency

Mongolia: children 6-59 months

32.4 21.8%

Mongolia: Non pregnant women 15-49 years

30%

Fiji: Women 15-49

years7.9% 1% 0%

Indonesia: Children

0.5 to 12 years4.6%(urban) 8.8%(rural)

0.4%(urban) 1.3%(rural)

43%(urban)

44.2%(rural)

Viet Nam: Children

6-12 years7.7%(urban) 4.5%(rural)



Malaysia: Children

4-12 years4.4% 4.4% 47.5%

Thailand: Children

0.5-13 years38.9%(rural) 3.8%(rural) 27.7%(rural)

United Nations Children’s Fund

UNICEF East Asia and Regional Office (EAPRO)

19 Phra Atit Road Bangkok 10200 Thailand

Website: www.unicef.org/eapro

E-mail: [email protected]

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