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Zita Weise Prinzo Evidence and Programme Guidance Department of Nutrition for Health and Development WHO Geneva Informal Consultation with Member States and UN agencies on A proposed set of indicators for the Global Monitoring Framework for Maternal, Infant and Young Child Nutrition WHO/HQ, Geneva, 30 September 1 October 2013 Reduce and maintain childhood wasting to less than 5 %

Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

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Page 1: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Zita Weise Prinzo Evidence and Programme Guidance Department of Nutrition for Health and Development WHO Geneva

Informal Consultation with Member States and UN agencies on

A proposed set of indicators for the Global Monitoring Framework for

Maternal, Infant and Young Child Nutrition

WHO/HQ, Geneva, 30 September – 1 October 2013

Reduce and maintain childhood

wasting to less than 5 %

Page 2: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Outline

• Background for target – Rationale

– Definition

• Logical framework joining the indicators

• Proposed outcome indicators – Strengths

– Limitations

– Data availability

• Proposed process indicators – Strengths

– Limitations

– Data availability

Page 3: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Background

• Wasting is defined as a low weight-for-height.

• Wasting or thinness is due to a recent and severe process of weight loss, often associated with insufficient food intake (nutrient and energy density), and disease.

• Typically, the prevalence of wasting in young children peeks in the second year of life.

Page 4: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Background

• 51 million children are wasted globally

• 17 million of these are severely wasted and at high risk of mortality

• Wasting prevalence in 2012 was almost 8% globally of these 3% were severely wasted

• 69% of all wasted children lived in Asia and 23% in Africa

• 71% of all severely wasted children lived in Asia and 28% in Africa

• 64 countries reported wasting rates > 5%

Page 5: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Rationale

• Where the prevalence of wasting is high there is a parallel increase in morbidity and mortality.

• Children who are severely wasted need urgent medical and special nutritional care.

• Children who are moderately wasted require increased intake of energy and essential nutrients and treatment of any associated medical conditions.

• Undernutrition is an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles.

Page 6: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Definition

Children aged < 5 years wasted (%):

Percentage of weight-for-height less than -2 standard deviations of

the WHO Child Growth Standards median among children aged 0 to

5 years

Page 7: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Wasting and stunting

Serial episodes of wasting will affect stunting prevalence • In 2/3 severely malnourished children, recovery of at least

85% WL required before resuming linear growth (Jamaica: Walker & Golden, 1988)

• Wasting (<-2 SD), highly variable WLZ, or negative changes in WLZ between 6-17 mo increase risk of linear growth retardation by age 18-24 mo (8 cohort studies, 4 countries: Richard et al, 2012)

Page 8: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Actions to address wasting

• Preventive interventions:

• Access to nutrient rich foods and to health care

• Improved nutrition and health knowledge and practices

• Promotion of exclusive breastfeeding and improved complementary feeding practices

• Improved water and sanitation systems and hygiene practices to protect against communicable diseases.

Page 9: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Actions to address wasting

• Appropriate treatment of children with severe acute malnutrition: • Community screening - early identification

• Treatment of infections

• Access to therapeutic foods

• Inpatient management (medical complications)

• Monitoring and follow-up.

• Appropriate treatment of children with moderate acute malnutrition: • Optimal use of locally available foods

• Where necessary specially formulated foods.

Page 10: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Agriculture and Food Systems • Food production and

processing •Availability of micronutrient-

rich foods • Food safety and quality

Inadequate practices • Infrequent feeding • Inadequate feeding

during and after illness • Thin food consistency • Feeding insufficient

quantities • Non-responsive feeding

Health and Healthcare • Access to healthcare • Qualified healthcare

providers • Availability of supplies

•Infrastructure •Health care systems and

policies

Education • Access to quality education

• Qualified teachers • Qualified health educators • Infrastructure (schools and

training institutions)

Food and water safety • Contaminated food and

water • Poor hygiene practices • Unsafe storage and preparation of foods

Concurrent problems & short-term consequences Long-term consequences

Poor quality foods • Poor micronutrient

quality • Low dietary diversity and intake of animal-

source foods • Anti-nutrient content • Low energy content of

complementary foods

Water, Sanitation and Environment

• Water and sanitation infrastructure and services

• Population density •Climate change •Urbanization

• Natural and manmade disasters

Political economy • Food prices and trade policy

• Marketing regulations • Political stability

• Poverty, income and wealth • Financial services

• Employment and livelihoods

Community and societal factors

Inadequate Complementary Feeding

Stunted Growth and Development

Health ↑Mortality

↑Morbidities

Developmental ↓Cognitive, motor,

and language development

Economic ↑Health

expenditures ↑Opportunity costs for care of sick child

Economic ↓ Work capacity

↓ Work productivity

Developmental ↓School

performance ↓ Learning capacity

Unachieved potential

Health ↓Adult stature ↑Obesity and associated co-

morbidities ↓ Reproductive

health

Infection

Clinical and subclinical infection

• Enteric infection: Diarrhoeal disease,

environmental enteropathy, helminths • Respiratory infections

• Malaria • Reduced appetite due to

infection • Inflammation

Household and family factors

Maternal factors • Poor nutrition during

pre-conception, pregnancy and lactation • Short maternal stature

• Infection • Adolescent pregnancy

• Mental health •IUGR and preterm birth • Short birth spacing • Hypertension

Inadequate practices • Delayed initiation • Non-exclusive breastfeeding

• Early cessation of breastfeeding

Context

Causes

Consequences

Society and Culture • Beliefs and norms

• Social support networks • Child caregivers (parental

and non-parental) • Women’s status

Home environment • Inadequate child

stimulation and activity • Poor care practices •Inadequate sanitation

and water supply • Food insecurity

• Inappropriate intra-household food allocation • Low caregiver education

Breastfeeding

PO1

IO1: malaria IO2: Diarrhea

PR1: Adequacy PR8: Diversity

PR2: Water PR3: Sanitation

PR4: ITN; PR5: ORS PR9: Immunization

PR6: dietary energy PR10: HH exp on food

Page 11: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Primary outcome indicator

• Prevalence of low weight-for-height in children <5 years of age defined as <-2 standard deviations of the WHO Child Growth Standards median • Rationale: To measure nutritional imbalance and malnutrition resulting in

wasting.

• Data availability: Most nutrition surveys, e.g. MICS, DHS, SMART and other national/sub-national surveys

• Limitations:

• Wasting is very responsive to infection and food availability. A child's weight relative to its height can drop quickly and also recover quickly with appropriate interventions

• Annual incidence would be more accurate estimate for this condition (however this data not available)

Page 12: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Intermediate outcome indicators (see stunting)

– Prevalence of malaria

• In malaria endemic areas, Global Health Observatory

– Incidence of diarrhea in under-fives

• Weak cross-sectional association with stunting , Global Health Observatory

Page 13: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Intermediate outcome indicators (optional)

• Prevalence of measles, rubella, pertussis, polio

• Rationale: To measure vaccine-preventable diseases, proxy also for

accessibility to health services

• Data availability: World Health Statistics (number of reported cases; immunization status)

• Limitations: No direct relationship between some of the diseases and wasting, e.g. polio

Page 14: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Process indicators (see stunting)

Complementary feeding

• % 6-23 month-olds receiving a minimum acceptable diet

• Mean dietary diversity score (minimum diversity for 6-23 month-olds)

Data availability

• From DHS and MICS, UNICEF

• For adults, FAO statistics (HH consumption surveys)

Page 15: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Process indicators (seestunting)

Household and family factors

• % population using an improved water source

• % population using improved sanitation facilities

• % population below minimum dietary energy consumption

• Proportion of average household expenditure on food of the bottom three deciles

Data availability • WHO Global Health Observatory (World Health Statistics)

• MICS (UNICEF)

• FAO HH Food consumption surveys

Page 16: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Process indicators (see stunting)

Page 17: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Process indicators

• Proportion of children with severe acute malnutrition having access to appropriate treatment including therapeutic foods. • Rationale: Effective treatment available to manage severe wasting

• Data availability: Records, special surveys

• Limitations:

• Information on severe acute malnutrition collected which includes children with oedema and/or MUAC less than 115 mm, no information on severe wasting alone

• Does not give Information on children with severe acute malnutrition who get treated over the total number of children who need treatment, and no information on actual recovery.

Page 18: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Process indicators (optional)

• Proportion of children born to HIV-positive women who are feeding in line with national guidelines on HIV and infant feeding

• Rationale: To prevent infants from being HIV+ and at greater risk of becoming wasted

• Data availability: Records, surveys

• Limitations: Any infant who is not fed adequately and appropriately is at risk of becoming wasted

Page 19: Reduce and maintain childhood wasting to less than 5 %...•Typically, the prevalence of wasting in young children peeks in the second year of life. Background •51 million children

Process indicators (optional to explore)

• Proportion of children with moderate acute malnutrition having access to appropriate supplementary foods.

• Rationale: In specific emergency and food insecure settings effective

treatment with supplementary foods can reduce prevalence of wasting

• Data availability: Records, special surveys

• Limitations:

• No clear information on children with moderate wasting who get treated over the total number of children who need treatment.

• Often MUAC is used as an indicator to screen children (moderate acute malnutrition)