THEME 1: DATA REVOLUTION AND INNOVATIVE APPROACHES FOR ASSESSING PROGRESS IN NUTRITION OUTCOMES

Suneetha KadiyalaSenior-lecturer in Nutrition Sensitive Development London School of Hygiene & Tropical Medicine (LSHTM), UKLeverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH)

SDG2: TARGET 2.2

By 2030 , end a l l fo rms o f malnutr i t ion , inc lud ing achiev ing, by 2025 , the internat iona l ly agreed targets on s tunt ing and wast ing in ch i ldren under 5 years o f age, and address the nut r i t iona l needs o f ado lescent g i r l s , pregnant and lactat ing women and o lder p ersons .

GLOBAL NUTRITION TARGETS AND PROGRESS TO DATE

WHAT ARE THE GLOBAL NUTRITION TARGETS We had one nutrition target for MDG1

6 World Health Assembly Targets

Maternal only in one target!!

WHAT ARE THE GLOBAL NUTRITION TARGETS We had one nutrition target for MDG1

6 World Health Assembly Targets

Source: Global Nutrition Report, 2015

NUMBER OF COUNTRIES ON COURSE TO MEET 5 WHA TARGETS

Source: Global Nutrition Report, 2015

S D G 2 : TA R G E T 2 . 2

B y 2 0 3 0 , e n d a l l f o r m s o f m a l n u t r i t i o n , i n c l u d i n g a c h i e v i n g , b y 2 0 2 5 , t h e i n t e r n a t i o n a l l y a g r e e d t a r g e t s o n s t u n t i n g a n d w a s t i n g i n c h i l d r e n u n d e r 5 y e a r s o f a g e , a n d a d d r e s s t h e n u t r i t i o n a l n e e d s o f a d o l e s c e n t g i r l s , p r e g n a n t a n d l a c t a t i n g w o m e n a n d o l d e r p e r s o n s

Anemia WHA target?

CHILD ANTHROPOMETRY INDICATORS

NUTRITION INDICATORS REVIEWED AT THE SECOND IAEG-SDG MEETING

o Consensus on stunting and wasting • Both are green indicators

o But no other specific indicators are listed to evaluate progress on other nutrition outcomes and populations of interest to SDG2.• But commitment to internationally agreed nutrition targets articulated

Source: Results of the list of indicators reviewed at the second IAEG-SDG meeting, 2nd November 2015

WHAT DO WE KNOW ABOUT THE GREEN INDICATORS?: STUNTING AND WASTING (OVERWEIGHT)

Standard nutrition indicator?

Yes • Chronic undernutrition: HAZ<-2SD ; • Acute malnutrition: WHZ<-2SD*• Overweight: WHZ>+2SD

Scientific consensus? Yes, but…

Widespread current data systems available?

Yes • Populations surveys such as DHS &

MICS

Coverage and representativeness

• Nationally representative • At the disaggregated level,

representative at urban/rural; state/province level

BUT HOW WELL DO WE MEASURE AND TRACK ACUTE MALNUTRITION? (1)

o Nutritional oedema not included in the WHO classification of wasting

o Most population surveys do not routinely measure mid-upper arm circumference (MUAC)•Moderate acute malnutrition: MUAC ≥115 mm and <125 mm• Severe acute malnutrition: MUAC<115mm

o MUAC and WHZ indicators report a similar prevalence of acute malnutrition, but identify different children • 40-60% overlap

BUT HOW WELL DO WE MEASURE AND TRACK ACUTE MALNUTRITION? (2)

o Should MUAC be considered as a standard indicator for wasting for SDG2?•Better at early detection of acute malnutrition•Better predictor of mortality than the WHZ• Independent of body shape • Recommended programmatic approach to screen for treatment

o Current global estimates probably underestimate the actual annual burden of wasting•Wasting is episodic •Current surveys miss a relatively large proportion of incident cases occurring overtime •Seasonal peaks are probably underestimated

GLOBAL SHARE OF DATA ON CHILD ANTHROPOMETRY INDICATORS

Issues that need to be tackledo Frequency of data collection across ALL LMICs

o Improve sampling methodology to monitor vulnerable populations and equity in progress•Migrants and displaced persons•Ethnic minorities

o Include older children and adolescents (5-19 years) in anthropometry measurements

o Improve data systems to measure incidence of acute malnutrition

Source: UNICEF, Global share of data on child anthropometry indicators

IMPROVE DATA ON ACUTE MALNUTRITION

1. Include the following in current populations surveys MUACNutritional edema

2. Invest in research to resolve the MUAC and WHZ debateWhat makes sense for ongoing monitoring and evaluation if these measures identify different children, even though the overall prevalence estimates tend to be similar?

3. Improve incidence data. But how?Establish data systems in high burden countries Frequent (2-4 times/year) data collection Sentinel sites? Repeated small-scale surveys?

DATA FOR OTHER INTERNATIONALLY AGREED TARGETS

WHAT DO WE KNOW ABOUT LOW BIRTH WEIGHT?

Standard nutrition indicator?

Yes • Wight at birth<2500gms

Scientific consensus? Yes

Widespread current data systems available?

NO • No time series national level

estimates • DHS & MICS (about ½ data points)• National household/facility based

surveys (about 1/3rd data points)• Administrative records (1/5th) • Several methodological challenges

Coverage and representativeness

• Only ½ the children weighted at birth (excluding China)

A study by UNICEF, JHU and LSHTM will provide estimates and time trends

But investments in data systems will need to be made

ANEMIA AND OTHER MICRONUTRIENT DEFICIENCIES

Standard nutrition indicator?

Yes, only for anemia

Scientific consensus?

• Yes on anemia, but does not take into account the burden Thalassemias, which remains under investigated

• Yes, for some other MNs. But Vitamin A, Zinc and Iodine measured by coverage, not the right indicators to assess the change in nutrition status

Widespread current data systems available?

NO • For anemia, DHS and MICS could more consistently

collect data on anemia using the current assessment methods

• Special surveys by WHO Vita- min and Mineral Nutrition Information System (VMNIS), but not currently amenable for consistent monitoring

• Data on prevalence of micronutrient deficiencies is patchy at best

• Field friendly assessment methods for micronutrient biomarkers need to be developed, tested and scaled up- Example, dried blood spots

MINIMUM DIETARY DIVERSITY AS A PROXY INDICATOR FOR DIET QUALITY AS SDG2:2.2 TARGET

o Currently not among the WHA nutrition targets, but embedded in SDG2: 2.1

o But central to SDG2 theory of change

o Individual DD scores (IDDS) are valid proxy indicators of diet quality (access)•women (micronutrient adequacy)•children (density of the diet)

o Need to be tested for cross-country comparisons• Careful validation of these indicators for different purposes (for example, monitoring, evaluation, targeting) needed

o Should be included consistently in population surveys (several DHS surveys already include this)

THE ELDERLY…

NUTRITION IN ELDERLY

o Height based indicators inappropriate

o ?experience based indicators?

o Need a strong push to • Identify which nutrition indicators to measure•Develop and validate field friendly assessment methods

o Develop/expand data systems

DATA SYSTEMS ARE INADEQUATE

Source: Global Nutrition Report , 2015

INVESTMENTS REQUIRED (1)

o Anthropometry• Improve coverage, frequency and harmonization of population surveys for cross-country comparison•Consider inclusion of edema and MUAC• Improve sampling methodologies to cover vulnerable groups and adolescents and track equity in progress• Invest in building surveillance systems to track incidence on acute malnutrition

o Experience based proxy indicators of diet quality • Continue embedding MDD indicators in the population surveys• Validate for cross-country comparison

But where are women?

Need for inclusion of nutrition outcomes among women explicitly as key SDG 2.2 indicators. • BMI based indicators for chronic energy

deficiency and overweight• Experience based indicators (W-MDD

score)• Anemia

Notice: the current nutrition targets do not have any other nutrition-related chronic diseases beyond overweight and obesity.

INVESTMENTS REQUIRED (2)

oMicronutrient status •Continue to include Hb in current population surveys • Invest in field-based methods to assess multiple biomarkers• Investigate how to institutionalize WHO-VMNIS in parallel with population surveys or embed them in national nutritional surveillance systems

o Low brithweight• need nationally representative systems

oNutrition in elderly• Need to start with the basics!