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Chris Auricht - overview of population undernutrition
1. Overview of
Population
undernutrition in
eastern and southern
Africa
Australian International
Food Security Centre
(AIFSC)
Christopher Auricht
chris@auricht.com and
Anne Marie Sanderson
aifsc@aciar.gov.au
NAIROBI
10 Sep 2012
2. 2
Outline
Elements and consequences of
maternal and child undernutrition
and food security
Global and Regional SSA Context
East and Southern Africa Perspective
3. 3
Elements and consequences
Maternal and undernutrtion responsible
for > one third of child deaths
Undernutrition – includes:
Stunting
Wasting
Underweight
Micronutrient deficiencies - deficiencies of
essential vitamins and minerals
Note - ‘malnutrition’ includes both undernutrion and overnutrition or
obesity
4. 4
Consequences of undernutrition i.e.
why is undernutrition important?
Undernourished children and those not
optimally breastfed, or those suffering
from micronutrient deficiencies have
substantially lower chances of survival
than those who are well nourished.
Undernutrition in children increased
likelihood of:
serious infection
death from common childhood illnesses
e.g. diarrhoea, measles, pneumonia and
malaraia, as well as HIV/AIDS
5. 5
Consequences of undernutrition cont.
Chronic undernutrion in early childhood
Reduced cognitive and physical
development disadvantaged throughout life
Nutrition status affected prior to conception
Highly correlated to mother’s nutrition status
prior to and during pregnancy
Cyclical
chronicallyundernorhised woman give birth to
undernourished child
6. 6
Importance of essential vitamins
Micronutrients provide essential vitamins and
minerals
Deficiencies occur when body doesn’t have
sufficient amounts due to
dietary intake and/or
insufficient absorption and/or
suboptimal utilisation
Consequences include
iron deficiency anaemia
iodine deficiency disorders
blindness
7. 7
Importance of diet
Lackof adequate diet for a couple
months or more between conception
and 2 years of age deprives children of
essential nutrients
Micronutrientdeficiencies
Constrained development
Stunting
Beyondtwo years of age most damage
cannot be reversed
8. 8
Food security calendar and scale of rural hunger
Nearly one billion people experience debilitation,
health-threatening hunger each year
4 out of 5 of these people are rural farmers
Trends in maize shortage in Zambia
Percentage of farm households with maize shortage
The Hunger
Period
9. 9
Measures and Indicators of undernutrition
A considerable body of work carried out at
global, national and subnational levels
addressing population nutrition
Demographic and Health Surveys include
indicators / measures to help track trends over
time.
Involve key measurements of children, and
women of child-bearing age (15-49 years).
Specific indicators include wasting, stunting and
underweight status amongst children under 5 (0-
59 months), maternal thinness or body mass
index (DMI) and prevalence of low birthweight
babies ( < 2500 g)
10. 10
Child Undernutrition Measures
and Indicators
WHO Child Growth Standards 2006
Standard distribution of height and weight of
children < 5 years (0 – 59 months)
Assessment of undernourishment based on
comparison with WHO growth standards
Rates of undernutrition expressed in standard
deviations or Z-scores from the median of this
distribution
11. 11
Child Undernutrition cont
Anthropometric measures in
children < 5 years
Wasting – low weight for height
Stunting – low height for age
Underweight – low weight for age
12. 12
Child undernutrition metrics
Severe % < - 3Z–scores
Moderate % <-2Z-
scores
Population prevalence
– low, medium, high
and very high
13. 13
Indicator Prevalence (%)
Low Medium High Very high
Underweight
(% with weight-for-age <-2 Z-
<10 10 – 19 20 -29 ≥30
scores)
Wasting
(% with weight-for-height <-2 Z-
<5 5-9 10 -14 ≥15
scores)
Stunting
(% with height-for-age <-2 Z-
<20 20 - 29 30-39 ≥40
scores)
Source: www.who.org
14. 14
Maternal undernutrition
Women 15 – 49 years (child-
bearing age)
Indicators include:
Body Mass Index (Thinness)
Height (Stature)
Micronutrient deficiencies (Iron,
Iodine, Vit A)
15. 15
Maternal undernutrition indicators
Short stature – increased risk of
obstetric complications
Low pre-pregnancy BMI ( <18.5) –
risk factor for child development
and pregnancy outcomes
Low iodine – risk for child
development
Low iron – risk for poor birth
outcomes
17. 17
Food Security
“Food security exists when all people,
at all times, have physical and
economic access to sufficient, safe
and nutritious food to meet their
dietary needs and food preferences for
an active and healthy life.”
World Food Summit 1996
18. 18
Global Temporal Dimension
Percentage urban and urban agglomerations by size class
2011
1980
2025
1960
Source: UN Pop Division World Urbanisation Prospects, 2011 Revision
http://esa.un.org/unpd/wup/Maps/maps_overview.htm
19. 19
Population 2000 and 2040 Sub-
Saharan Africa (Millions)
Population 2000 2005 2010 2015 2020 2030 2040
Total Pop 659 746 843 952 1,071 1,333 1,623
Rural Pop 447 491 537 586 635 724 795
Urban 212 255 306 366 436 609 828
Agric Pop 403 437 472 508 544
Females in
78 87 97 109 121
Ag
Source: UN Pop Division World Urbanisation Prospects, 2011 Revision and FAOStat
http://esa.un.org/unpd/wup/Maps/maps_overview.htm and
http://faostat.fao.org/site/550/DesktopDefault.aspx?PageID=550#ancor
21. 21
Trends in Stunting and underweight
Many African counties < 0.5
probability of meeting MDG
1 target (underweight)
Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic
analysis of population representative data. Gretchen A Stevens, Mariel M Finucane, Christopher J Paciorek, Seth R Flaxman, Richard A
White, Abigail J Donner, Majid Ezzati, on behalf of Nutrition Impact Model Study Group (Child Growth). Lancet July 5,2012
23. 23
Number of countries where stunting rates are
going up, down or are unchanged (latest
survey minus the previous one)
Region Total Improving No Deteriorating
number of change
countries
Africa 29 12 6 11
Asia 20 13 6 1
S. & Central 14 6 7 1
America and
Caribbean
Total 63 31 19 13
SCN 6th World Nutrition Report. 2011
24. 24
The Undernutrition Paradigm
Close links exist amongst food security
(including agriculture), social protection and
health
Links also exist between food security, nutrition
and the broader determinants of poverty
(including education, water supply, sanitation
etc) and cross-cutting issues e.g. gender
equity and governance
Such linkages between poverty, food
insecurity and other causes and
consequences often presented in frameworks
27. 27
AIFSC South and Eastern
Africa Perspective
Burundi
Ethiopia
Kenya
Malawi
Mozambique
Rwanda
Uganda
Tanzania
Zambia
28. Child undernutrition rates
Prevalence of undernutrition in children under the age of five years
(percent)
Underweight Stunting Wasting
(Weight for age) (Height for age) (Weight-for-height)
Country Year <-2 Z-scores <-2 Z-scores <-2 Z-scores
Burundi 2010
28.8 57.7 5.8
Ethiopia 2011
28.7 44.4 9.7
Kenya 2008-09
16.0 35.0 7.0
Malawi 2010
12.8 47.1 4.0
Mozambique 2011
14.9 42.6 5.9
Rwanda 2010
11.4 44.2 2.8
Uganda 2006
15.9 38.1 6.1
United Republic of Tanzania 2010
15.8 42.0 4.8
Zambia 2007 14.6 45.4 5.2
Mean - 17.6 44.1 5.7
Source: National Surveys
29. Children
Wasting
Indicator Prevalence (%)
Low Medium High Very high
Underweight
(% with weight-for-age <-2 Z-
<10 10 – 19 20 -29 ≥30
scores)
Wasting
(% with weight-for-height <-2 Z-
<5 5-9 10 -14 ≥15
scores)
Stunting
(% with height-for-age <-2 Z-
<20 20 - 29 30-39 ≥40
scores)
30. Children
Underweight
Indicator Prevalence (%)
Low Medium High Very high
Underweight
(% with weight-for-age <-2 Z-
<10 10 – 19 20 -29 ≥30
scores)
Wasting
(% with weight-for-height <-2 Z-
<5 5-9 10 -14 ≥15
scores)
Stunting
(% with height-for-age <-2 Z-
<20 20 - 29 30-39 ≥40
scores)
31. Children
Stunting
Indicator Prevalence (%)
Low Medium High Very high
Underweight
(% with weight-for-age <-2 Z-
<10 10 – 19 20 -29 ≥30
scores)
Wasting
(% with weight-for-height <-2 Z-
<5 5-9 10 -14 ≥15
scores)
Stunting
(% with height-for-age <-2 Z-
<20 20 - 29 30-39 ≥40
scores)
32. Maternal undernutrition
Latest Women 15 – 49 Women 15 –
available with height 49 with BMI
data <145cm (%) <18.5 (%)
Burundi - - -
Ethiopia 2011 3.4 26.9
Kenya 2008-09 1.2 12.3
Malawi 2010 2.4 8.8
Mozambique 2003 4.9 8.6
Rwanda 2010 1.8 8.2
Uganda 2006 1.9 12.1
United 2010 3.4 11.4
Republic of
Tanzania
Zambia 2007 2.6 9.6
Mean - 2.7 12.2
34. Vitmain A - Women
Year Population with serum Public health
retinol <0.7µmol/L (%) problem
Burundi - 12.2 Moderate
Ethiopia 1997 13.2 Moderate
Kenya 1998 17.3 Moderate
Malawi 1999 13.7 Moderate
Mozambique 2002 14.3 Moderate
Rwanda 1996 6.2 Mild
Uganda 2001 23.3 Severe
United Republic 2001 14.8 Moderate
of Tanzania
Zambia 2001 14.0 Moderate
35. Vitamin A - Children
Year Population with serum Public health
retinol <0.7µmol/L (%) problem
Burundi 2005 27.9 Severe
Ethiopia 1996/97 46.1 Severe
Kenya 1999 84.4 Severe
Malawi 2001 59.2 Severe
Mozambique 2002 68.8 Severe
Rwanda 1996 6.4 Mild
Uganda 2001 27.9 Severe
United 1997 24.2 Severe
Republic of
Tanzania
Zambia 2003 54.1 Severe
36. Iodine deficiency
Needed from the mother during pregnancy
Deficiencies cause irreversible:
Cretinism (mental retardation)
Deaf-mutism
Dwarfism
Spastic palsy of the lower limbs
Spontaneous abortion and neontal deaths
Goitre – enlargement of the thyroid
37.
38. Iodine nutrition
Date % population Classification Classification of iodine
with UI <100 of iodine nutrition
µg/L intake
Burundi
Ethiopia 2000 68.4 Insufficient Mild iodine deficiency
Kenya 1994 36.7 Adequate Optimal iodine
nutrition
Malawi No data in 2004
WHO database
Mozambique 1998 65.4 Insufficient Mild iodine deficiency
Rwanda 1996 0.0 More than Risk of IIH in
adequate susceptible groups
Uganda 1999 11.9 Excessive Risk of adverse health
consequences
United Republic of 1996 37.7 Adequate Optimal iodine
Tanzania nutrition
Zambia 1993 72.0 Insufficient Mild iodine deficiency
39. Iron deficiency
Most common nutritional disorder
Important micronutrient for oxygen transport
Lowlevels of consumption of meat, fish and
poultry
Loss
or destruction of red blood cells by hook
worm and malaria
Measured by low levels of haemoglobin in the
blood – low capacity to carry oxygen
40. Anaemia -
Public health significance
Prevalence of any anaemia (%) Category of public health significance (WHO)
≤4.9 No public health problem
5.0 – 19.9 Mild
20.0 – 39.9 Moderate
≥40 Severe
41.
42. Anaemia
% of children 6 – 59 months with % Women 15 – 49 with ‘any’
‘any’ anaemia (<12.0 g/dl anaemia (<12.0 g/dl
haemoglobin) haemoglobin)
Burundi 44.6 18.5
Ethiopia 44.3 16.6
Kenya 69.0 46.4
Malawi 62.5 28.0
Mozambique 68.7 53.9
Rwanda 38.2 17.3
Uganda 72.6 49
Tanzania 58.6 40.1
Zambia 52.9 29.1
43. 43
Overview Findings
Provided a snapshot of population nutrition for
selected countries using a series of standard
indicators
Evidence indicates that stunting and anaemia
are the most serious undernutrition issues
Relationships between poverty, food security
and undernutrition are strong
Addressing poverty and food security
(agriculture production) and improving
livelihoods critical to solution
44. 44
Facts (Agriculture Perspective)
According to CGIAR analysis
One billion of the worlds poor within Africa and
Asia (those living on less than $1 per day) are
fed primarily by:
hundreds of millions of small-holder farmers
(often with less than 2 ha of land, several
crops, and a cow or two), or
Herders (most with fewer than five large
animals)
This table shows an overview of the stunting, wasting and underweightprevalence for childrenunder 5 in the selected countries. The red shows a very high and serious rate of stunting in particular, an indication that the nutrtionproblems are underlying, chronic and linked to the longer term, chronic drivers of malnutrition. During the famine in Niger for example, rates of wasting are reachingabove 20 percent – sothings are gettingserious. The recenthorn of Africa crisismay have alsoimpacted on these rates of wasting in particular, as acute and short termshocks to foodsecurity or waves of illnessessuch as cholera or measlesthatcanspike in situations involvingdisplcament or camps. The focus of the workshops in Nairobi willbe to discussthese profiles with the local professionals to see how the underlyingfoodsecurity and nutrtion issues alignwith the capacities of the AIFSC.
Wealsomapped out the distributrionsat the subnationallevel. The distribution was not uniormacrossentire countries withsome areas affected more thanothers. This isunderweight for example. So Redmeansworse, youcanseethat rates of underweight are mostserious in Ethiopia, whereas southern Mozambique isn’tsobad. Again – thesemapswillbesubject of discussion at the workshop, where countries maywish to drill down on important sub national trends in their population undernutrition.
Againhereis the outcome for maternalindicators. Prevalence of short stature is not subkect to any standards or cutoff points for levels of public healthseveretiybecauseitis not somethingthattherecanbe an islated public healthresponse to. Short stature is a hugeproblem in southAsia in particular and causes a lot of maternalhealth complications. The rates of low BMI however are classified by the world health organisation and thisiscolourcodedsothat green meanslow, light organe medium and the dark orange as high whichis a serious situation in Ethiopia. Again – the BMI of women in thisage group maywell have been shocked and affected by the recentfoodinsecurity and instability, so the outcomes for the nextgenerationmaybeaffected by the low BMI of the currentpreganant and lactatingwomen in the famine affected populations.
An estimated 33 percent of preschoolagedchildrenglobally are vitmain A deficiencywhichis about 190 million children. This places them as mentioned, at an increasedrisk of infectiousdiseases, and blindness.
This table is an extractfrom the WHO Global Database on Vitmain A. There is more up to date data, but many of the national surveysusedotherindicators of vitmain A nutrition such as consumption of vitmain A richfoods. I chose this set becauseit has one indicatoramongst all the countries. WHO classifies thesepercentages as moderate, mild and severe.Amongst the focus countries shownheremost are classified as ‘moderate’ with the exception of Rwanda with ‘mild’ and Uganda with a ‘severe’ problem. Again, thesestats are quiteold, and willbe the subject of scrutiny and discussion in the workshop nextweek.
All of the focus countries with the exception of Rwanda are reported in the WHO Global database as havingseverelevels of vitmain A deficiency in preschoolagedchildren..
A second micronutrientisiodine. Iodineis essential for function of ourthyroid gland, and mostimportantlyitis important for the development of ourbrain in utero. The iodine nutrition of a baby isdirectlydependent on the iodine nutrition of theirmotherduringpregnancy. Deficiencies in iodine, in the mother – can lead to irreverible damage includingcertinism a form of mental retardation, itcan cause deafness and mnutness, dwarfism and canalso affect development of the lowerlimbs. Iodinedeficiencyis the mostcommonpreventable cause of mental retardation globally.
Iodinedeficiencycanbemeasured on urinaryiodine concentration. Hereis a map of hte global ditributionDoesanyone know whereweget out iodinefrom? One source? Doesanyone know a common cause of deficiencylinked to geology and soil science?Doesanyone know how iodinedeficiencyiscombattedat the population scale?Rates of saltiodinsation are alsocommonlycollected as an indicator of iodinedeficiency as is Total GiotrePrevalencewhichmeasures how many people are affected by abnormalgrowth of the thyriod gland.
Most of the focus countries have close to universalcoverage of iodisedsalt, sothisis a problemthatisbecomingless of an issue. Iodinedeficiencyislike the hole in the ozone layer of nutrition. Whereasstunintingislikeclimate change – manycomplexunderlying and interconnectingfactorswith out a single silverbullet of a solution.
The public healthsignificance of rates of anaemiaisalsoclassified by WHO. People with concentrations of haemoglobin <12 g/dl are conisderedanaemic and deficient in iron. If Lessthan 5% of the population have anaemiathisis not conisidered a public healthproblem, while rates above 40% in a particular population isconsidered a severeproblem.
Hereis the global distribution of anaemia. The darkercolourissevereanaemia, showingsub-Saharan Africa lit verysignificantly. You cansee the way in whichiscoincideswithbothlowincome countries and areas withendemic malaria.
Here are the rates of anaemia in the focus countries amongstchildren 6 – 59 months and in women 15 – 49. The red shows levelsconsidered to be ‘severe’ as they are greaterthan 40%. You will notice the drasticlevels of anaemiaamongstchildren in these countries. This couldberelated to the impacts of bothinadequatedietaryintake, as well as malria – which destroys redbloodcells; and otherparastic infections that affect redbloodcells.