1. Module 5: Nutritional assessment in
policy and programmatic application
By
Tina G. Sanghvi, PhD Senior Country Director Alive & Thrive, FHI360
Training on Assessment of Nutritional Status 18-22 December 2011
Date : 22 December 2011,
Venue: FPMU Meeting Room
The Training is organized by the National National Food Policy Capacity Strengthening Programme (NFPCSP) . The NFPCSP is jointly
implemented by the Food Planning and Monitoring Unit (FPMU), Ministry of Food and Disaster Management and Food and Agriculture
Organization of the United Nations (FAO) with the financial support of the EU and USAID.

2. Acknowledgements
• M. Ruel, IFPRI. Nutrition and economic growth A&T
Partners’ Meeting Hanoi, September 2011
• Lalita Bhattacharjee, FSNSP Dissemination Workshop.
December 13 December 13, 2011.
• Mahbub Hossain, BRAC. FSNSP Dissemination
Workshop. December 13, 2011
• John B. Mason. Keynote paper: Measuring hunger and
malnutrition.FAO Symposium 2002
• IFPRI. Alive & Thrive Baseline Survey 2011.
• Haider, Sanghvi et al. Alive & Thrive Formative Research
on IYCF. 2009.
Module 5: Program and Policy Application, Tina Sanghvi PhD

3. Session Overview
• Uses of data for policy & programs
– Examples
• Why dietary adequacy does not always equal
nutritional status
– Examples
Module 5: Program and Policy Application, Tina Sanghvi PhD

4. Indicators – Country Investment Plan
Key Indicators Baseline (‘07-’10) Final ‘15-’16)
Overall goal:
% People undernourished 27 17.5
% Child stunting 43 25
% Child underweight 41 33
Outcome/impact:
Food availability (food supplies) (rice supply & share)
Food access (income)
- Poverty rate < 2022 kcals/day 40 24
- Poverty rate < 1805 kcals/day 19.5 14
Food utilization
- Minimum acceptable 42 56
complementary feeding
(quantity & quality of CF 6-23 m)
Module 5: Program and Policy Application, Tina Sanghvi PhD

5. Uses of data for policy & programs
• How food & nutrition assessments are used:
– Define trends to trigger action
– Identify causes to design interventions
– Monitor & evaluate effects of programs & policies
• Choice of indicators & interpretation are key
Example: In Bangladesh, food and poverty trends
have improved. Fertility & mortality rates have
declined but malnutrition is stagnant. This is
triggering actions to find out the causes, evaluate
past programs and strengthen nutrition
interventions, e.g. CIP, NFP, POA, National
Nutrition Service to evaluate their future effects
Module 5: Program and Policy Application, Tina Sanghvi PhD

6. METHODS OF ASSESSING FOOD
SECURITY& NUTRITION & THEIR USE
Method Use
Trends analysis Research into Evaluation
causes
(1 ) FAO: DES/CV Main use: global and Not very useful except Not very useful
dietary energy supply regional level; always for broad inter-country
(coefficient of variation) under-estimates trends
(2) Household income Useful: national and Can be useful Useful
and expenditure survey subnational level
(3) Food consumption/ Useful: now available at Main use Main use
the national level, thus
individual intake (24- very useful, captures
hour) intra-HH food distrib.
(4) Anthropometry Useful at all levels, but Useful for physical Useful but should also
(mother, child weight & for physical malnutrition malnutrition not food have food security
height) and not food security security indicators
(5) Qualitative method Useful: national and Useful Useful
(food habits) subnational level

7. Questions that can be addressed by
different methods
Method Use
Trends analysis Causal analysis Evaluation
(1 ) FAO: DES/CV Is the supply of food in Is the cause of food Are food supply
dietary energy supply terms of calories/ insecurity & policies/programs
(coefficient of variation) energy improving to undernutrition due to working? Impact of
meet needs, if overall food supply?
climate change/
equitably distributed?
disasters on supplies?
(2) Household income Are no. of food secure Is the cause of Are programs working
and expenditure survey HH (in energy and problems due to low to reach the poor?
nutrients) improving? expenditures on food?
(3) Food consumption/ Are mothers and young Is the problem food Are programs for
children consuming availability/access or women and young
individual intake (24-hr) more adequate diets? dietary habits? children working?
(4) Anthropometry Is nutritional status No Does the program
(mother/child wt, ht) improving? improve nutrition of
mothers & children?
(5) Qualitative method Are food habits Are habits a barrier? Does the program
(food habits, frequency) improving? improve food habits?

8. How we present and interpret data
makes a difference: examples
Module 5: Program and Policy Application, Tina Sanghvi PhD

9. Trends in food intake (gms/capita/day)
All Urban Rural
1991-92 886 938 878
1995-96 914 931 911
2005 949 952 946
2010 1000 985 1005
•Intakes improving faster in rural areas,
•Averages hide disparities among economic groups
Module 5: Program and Policy Application, Tina Sanghvi PhD

10. Food available in grams per head per day
1050
1000
950
All
Urban
900
Rural
850
800
1991-92 1995-96 2005 2010
Module 5: Program and Policy Application, Tina Sanghvi PhD

11. Diversity:
-National supplies
-Household level
- Child’s diet
-Women’s diet
Module 5: Program and Policy Application, Tina Sanghvi PhD

12. Trends in food content adequacy
(gms/capita/day)
Food Recom. 2005 2010 Trend
Rice 390 440 416
Wheat 100 12 26
Vegetables 225 220 236
Pulses 30 14 14
Oil 20 16 21
Fish 45 42 49
Meat/eggs 34 20 25
Module 5: Program and Policy Application, Tina Sanghvi PhD

13. Content of food basket: improving
diversity
500
450
400
350 Rice
300 Wheat
250 Vegetables
200
Pulses
150
100 Oil
50 Fish
0 Meat/eggs
2005 2010
Module 5: Program and Policy Application, Tina Sanghvi PhD

14. Content of food basket: gaps in diversity
500
450
400
350 Recom.
300
250 2005
200
150 2010
100
50
0
Module 5: Program and Policy Application, Tina Sanghvi PhD

15. Dietary intake assessment is key
• RAP –low cost, primary method for collecting dietary data
(locally available /commonly consumed foods, dietary
habits, behaviour)
• Household surveys – provide data on foods consumed by
HH not individuals
• Point to which foods are major contributors to nutrients of
particular concern ( identify vulnerability/at risk of dietary
deficiency - e.g lack of animal foods; no fresh
vegetables/fruits, lack of DGLV/YOV–lack of vit. C & A in
diet)
• Food record and 24 hr recall methods of choice for
estimating mean intakes; quantitative dietary intake
methods to obtain individual nutrient intakes
• Take measurements for each individual on at least 2 non-
consecutive days to obtain intra-individual variation
Module 5: Program and Policy Application, Tina Sanghvi PhD

16. Why improving food security does not
necessarily remove undernutrition
Module 5: Program and Policy Application, Tina Sanghvi PhD

17. A&T Baseline: Stunting is High Even
in Food Secure Households
Bivariate
55
53.29
50
49.88
45 46.39 47.32 47.07
44.52
40
39.28
35
PERCENT STUNTED
35.38
30
Food secure
25
Mildly food insecure
20 22.99 23.14 Moderate food insecure
19.18 Severely food insecure
15
13.88
10
5
0
Vietnam Bangladesh Ethiopia
+ p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001
Module 5: Program and Policy Application, Tina Sanghvi PhD
Ruel; A&T Partners' Meeting, Hanoi
9/27/2011

18. Factors that determine nutritional status
Module 5: Program and Policy Application, Tina Sanghvi PhD

19. Adequate Complementary Feeding
100
90
By Wealth Quintiles By Age Groups
80
70
60
58
50
47 44 48 48
40
38 38 36
30
20 16
10
0
Lowest Second Middle Fourth Highest 6-8m 9-11m 12-17m 18-23m
BDHS 2007

20. Quality of Children’s Diets (BDHS, 2007)
Meat, Fish, Poultry and Eggs Consumed (< 24 h)
100
90
80 71 75
70 64
60 48
50
40 34
30 24
20 10
10 0 0 2
0
Age <2 m 2-3 m 4-5 m 6-7m 8-9m 10- 12- 16- 20- 24-
11m 15m 19m 23m 35m

21. Why is nutrition not improving?
• Knowledge: do people know what foods they should
consume by age, sex, occupation, physiological status?
• Do families have the resources/motivation to convert
knowledge to practice
• If food intakes (energy and nutrients) are
adequate, could there be intervening factors e.g. illness
• Pre-disposing factors: maternal undernutrition
seasonal food/income shortages, migration, illness
outbreaks, hygiene/sanitation, emergencies
• Importance of under 2’s
Module 5: Program and Policy Application, Tina Sanghvi PhD

22. Illustration of association between
dietary adequacy and anthropometry
Prevalence of % with % with Total under
under inadequate adequate or adequate
nutrition diet diet nutrition
% <-2SDs 20 10 30
% > -2SDs 0 70 70
Total sample 20 80 100
Note: 10% have adequate diets but are still undernourished due to other causes
Source : Mason, 2002 in “Measurement and Assessment of Food Deprivation and Undernutrition”, FAO

23. New focus on under 2 yr age group
• Most rapid decline in nutritional status
• Damage is largely not reversible
• Affects child growth + adult chronic diseases
• Affects brain development/learning as well as
physical development
• All national nutrition indicators focus on
young children, to improve MDG 1 have to
prevent under 2 decline in nutrition
Module 5: Program and Policy Application, Tina Sanghvi PhD

24. Goal: To reduce undernutrition, improve IYCF
Maximum decline at 3 to 15 months – period of IYCF
0.5
Length-for-age Z-score
EBF Complementary Feeding
0
------- ---------------------------
-0.5
Boys WHO Girls WHO
Growth of girls/ boys
Boys NCHS Girls NCHS
NCHS/WHO standards
-1
-1.5
-2
-2.5
1 3 5 7 9 11 13 15 17 19 21 23 25
Age (mo)
Growth data: Kuntal K. Saha et al, Food Nutr Bull. 2009; 30: 137-44
ICDDRB
Module 5: Program and Policy Application, Tina Sanghvi PhD

25. CF Provides Adequate Energy & Nutrients
Energy Required & Amount From Breastmilk & CF
1000
900
800 BF + CF
Calories per day
700 550
Exclusive BF
600
300 Compl. Food
500 200
400 Breastmilk
300
200
100
0
0-2 3-6 7-8 9-11 12-23
Age in months
½ Bati ½ Bati 1 Bati •At least 4 types
Recommended diet: 2 times 3 times 3 times •Hygienically
Daily + Daily + Daily+ prepared
Module 5: Program and Policy Application, Tina Sanghvi PhD
Bati = 250 ml

26. Indicators – Country Investment Plan
Key Indicators Baseline (‘07-’10) Final ‘15-’16)
Overall goal:
% People undernourished 27 17.5
% Child stunting 43 25
% Child underweight 41 33
Outcome/impact:
Food availability (food supplies) (rice supply & share)
Food access (income)
- Poverty rate < 2022 kcals/day 40 24
- Poverty rate < 1805 kcals/day 19.5 14
Food utilization
- Minimum acceptable 42 56
complementary feeding
(quantity & quality of CF 6-23 m)
Module 5: Program and Policy Application, Tina Sanghvi PhD

27. Minimum acceptable diet for under 2’s
• 3 conditions must be met:
– Breastfeeding
– Meal frequency as per age (2 to 3 times plus snacks)
– At least 4 different categories of food
Analysis should be used to focus BCC messages, how to
deal with HH food availability, mothers’ time
constraints etc.
Module 5: Program and Policy Application, Tina Sanghvi PhD

28. 100
Gaps in feeding
90
80
Median EBF 1.8 m 68
70
60
58
50
48 47
43 43 43
40 36
30
20 16
10
0
Breastfeeding Complementary Feeding
BDHS 2007, WHO (HKI 2006)
Module 5: Program and Policy Application, Tina Sanghvi PhD

29. Main messages
• What is needed to ensure food security &
nutrition results:
– Food availability - Food access - Food utilization
– Behavior change communications to promote
specific dietary & health habits
• Disaggregated analysis of trends, causes &
evaluations to design relevant interventions
• Equity: rational use of foods to reach the
disadvantaged & high risk ages; targeted
nutrition
Module 5: Program and Policy Application, Tina Sanghvi PhD

30. Conclusion
• Understanding what indicators & assessment
methods to use in policy & programs is key
• Food & dietary adequacy (total energy &
diversity) is a necessary, but not sufficient
condition for good nutrition
• Interpreting and presenting data in an
accurate and relevant manner is essential
• Assessments that do not lead to actions are
meaningless
Module 5: Program and Policy Application, Tina Sanghvi PhD