Food Nutrition Situation in Bangladesh Dr Tahmeed Ahmed

Food & Nutrition Situation in Bangladesh Dr Tahmeed Ahmed Director Centre for Nutrition & Food Security ICDDR, B Professor, Public Health Nutrition James P. Grant School of Public Health, BRAC University

Intergenerational Cycle of Malnutrition Higher mortality rate Impaired mental development Baby Low Birth Weight Untimely / inadequate weaning Frequent infections Inadequate food, health & care Foetal Malnutrition Child Stunted Malnourished ADULTS Reduced mental capacity Pregnancy Low Weight Gain Adolescent Stunted Higher maternal mortality Reduced mental capacity Llanos, Alvear, Uauy 2004

Different Types of Childhood Malnutrition Children Normal height for age Normal Wasted Stunted Underweight Low weight for height Low height for age Low weight for age

Stunting in Early Childhood & Later Development Outcomes Philippines, n=2489 Not stunted Mildly stunted Moderately/severely stunted Mendez MA, 1999

UNICEF; Black R, 2008

80 70 60 50 40 30 20 2 7 99 96 -1 19 19 19 9 2 9 4 0 0 20 0 0 7 90 10 19 89 - Percentage below -2 SD NCHS/WHO Reference Trends in Prevalence of Underweight in Under-5 Children in Bangladesh Ahmed T et al. In press.

Percentage below -2 SD NCHS/WHO Reference Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 70 60 50 40 30 Reasons for 20 the decline: Fertility rate reduced Measles vaccination now at 83% Family size smaller 4 electrification Rural 0 20 Microcredit? 20 0 -1 96 19 19 89 - 19 99 7 90 0 0 Vitamin A supplementation coverage at 88% 20 99 Increased food production & energy intake 9 1 7 Increased literacy 10 Ahmed T et al. In press.

80 70 60 50 40 30 20 2 7 99 96 -1 19 19 19 9 2 9 4 0 0 20 0 0 7 90 10 19 89 - Percentage below -2 SD NCHS/WHO Reference Trends in Prevalence of Underweight in Under-5 Children in Bangladesh Ahmed T et al. In press.

Percentage below -2 SD NCHS/WHO Reference Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 70 60 50 40 30 Assumptions 20 on reasons for the stagnation: 7 20 0 -1 96 19 19 89 - 19 99 7 90 • Increase in 10 inequity (increase in Gini coefficient) • Reduction in infant mortality rate resulting in more infants surviving but 0 4 0 with malnutrition 0 0 20 2 99 9 1 Ahmed T et al. In press.

80 70 60 50 40 Rate of reduction so far, 1. 27 percent points/yr 19 96 19 9 2 4 0 0 20 0 -1 19 99 7 0 0 0 20 1 10 7 Required rate of reduction, 1. 36 percent points/yr 90 20 5 30 19 89 - Percentage below -2 SD NCHS/WHO Reference Trends in Prevalence of Underweight in Under-5 Children in Bangladesh Ahmed T et al. In press.

B a nd ga 20 06 05 20 30 U da w an 5 20 0 35. 6 R ia op hi a di 6 40 Et bo am 47. 8 C ep al 20 0 -0 6 20 05 47. 0 N a di 7 20 0 50 In sh de la an g Percentage below -2 SD NCHS/WHO Reference Malnutrition is more common in Asia than in Sub-Saharan Africa 60 44. 9 38. 5 22. 6 20 20. 2 10 0

Trends of BMI of Women in Bangladesh Percent of women with BMI <18. 5 60 52. 0 50 45. 4 40 34. 3 29. 7 30 20 10 0 1996 -97 1999 -2000 2004 2007

On the Causes of Malnutrition Population increases in a geometric ratio, while the means of subsistence increases in an arithmetic ratio Thomas Malthus (1766 -1834)

Limited Land Mass with the Highest Population Density Population density in Bangladesh is 3 to 40 times higher than other ‘mega’ countries Bangladesh Japan Pakistan USA Nigeria Mexico Russia Brazil India Indonesia China

Korail Slum

• Close to 27% or 40 million live in urban areas • About 40% of Dhaka city population lives in slums • Dhaka is the fastest growing city Korail Slum

On the Causes of Malnutrition Famine and malnutrition are a result of a collapse of entitlements for a certain segment of society and the failure of the state to protect those entitlements. Amartya Sen

• Poverty • Food insecurity • Poor maternal nutrition • Low birth weight • Low rates of EBF • Lack of proper CF • Frequent illnesses BBS, World Bank, WFP 2005

Food Security in Urban Slums Household consumption Dhaka Chittagong Khulna Rajshahi All <2, 122 kcal/person/d 42. 4 56. 0 52. 0 61. 3 47. 8 <1, 805 kcal/person/d 24. 2 35. 8 38. 5 36. 0 29. 0 Urban food security Atlas, 2008

Share of Energy Intake in Bangladesh Staples Non-staple plants Fish and animal Howarth Bouis, 2006

Underweight (BMI <18. 5) Over weight (BMI ≥ 25) Diabetes mellitus Hypertension - Carbohydrates in diet - ‘Fast food’ culture - Lack of exercise Slum Non-slum 26. 7 14. 8 5. 5 12. 1 12. 9 34. 2 17. 0 21. 4

Severe Acute Malnutrition 2. 9% in Bangladesh ~500, 000 children At risk of death from • • • Hypoglycemia Hypothermia Infections

Admission 2 weeks A 2 yr old girl with dysentery, pneumonia Weighed only 3. 8 kg 4 weeks 5 weeks Treated with • therapeutic diets • antibiotics • micronutrients Diagnosed TB and treated appropriately

Timeliness: Early Versus Late Presentation

There has been some improvement but much more is required

The Lancet Series on Maternal and Child Undernutrition

Evidence-Based Interventions Systematic review of efficacy or effectiveness of 45 possible interventions that affect maternal and child undernutrition and nutrition-related outcomes, including: • Breastfeeding promotion • Complementary feeding promotion strategies with or without provision of food supplements • Micronutrient interventions (fortification & supplementation) • General supportive strategies for improving family and community nutrition and disease burden reduction • Interventions for the treatment of Bhutta ZA, Ahmed T et al. Lancet 2008 severe acute malnutrition

Interventions with Sufficient Evidence to Implement in All Countries Maternal and Birth Outcomes • Iron folate supplementation • Maternal supplements of multiple micronutrients • Maternal iodine through iodization of salt • Maternal calcium supplementation • Interventions to reduce tobacco consumption or indoor air pollution Newborn Babies Infants and Children • Promotion of breastfeeding (individual and group counseling) • Behavior change communication for improved complementary feeding • Zinc supplementation • Zinc in management of diarrhea • Vitamin A fortification or supplementation • Universal salt iodization • Handwashing or hygiene interventions • Treatment of SAM Bhutta ZA, Ahmed T et al. Lancet 2008

Interventions with Sufficient Evidence to Implement in All Countries Maternal and Birth Outcomes • Iron folate supplementation • Maternal supplements of multiple micronutrients Newborn Babies • Promotion of breastfeeding (individual and group counseling) • Maternal iodine through iodization of salt • Maternal calcium Hygiene interventions: supplementation • Interventions Reduce to reduce incidence of diarrhea tobacco consumption or reduce odds of stunting indoor air pollution Infants and Children • Promotion of breastfeeding (individual and group counseling) • Behavior change communication for improved complementary feeding • Zinc supplementation • Zinc in management of diarrhea • Vitamin by 30%, A fortification or supplementation • Universal salt iodization • Handwashing or hygiene interventions • Treatment of SAM Bhutta ZA, Ahmed T et al. Lancet 2008

Evidence-Based Interventions showing the most promise for reducing child deaths and future disease burden include: • • Breastfeeding promotion Appropriate complementary feeding Supplementation with vitamin A and zinc Appropriate management of severe acute malnutrition Bhutta ZA, Ahmed T et al. Lancet 2008

Coverage is most important ! Reduction in Reduction deaths in stunting 99% coverage 25% 35% % of DALYs averted 25% 90 % coverage 22% 32% 23% 70 % coverage 17% 27% 17% Bhutta ZA, Ahmed T et al. Lancet 2008

To eliminate stunting in the longer term, these Interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women’s empowerment.

Recommendations • Business as usual will not work • Need to think out of the box now • There is no one size that fits all, several strategies need to be tried

Recommendations • Immediate need is to improve existing services and scale them up – Primary health care focusing on child & maternal health and nutrition should be priority – Increase number of centers, staff – Improve quality of counseling – Rigorous monitoring of quality of services to reduce dissatisfaction with existing services

Recommendations • Primary health care intervention package should be expanded and improved – IFA tablets for adolescent girls, PLW – Breastfeeding & complementary feeding – Micronutrient powder for infants & young children – Management of moderate & severe acute malnutrition

Undernutrition hotspots need special attention – Monga-prone areas in the north – The coastal belt and char areas – Areas in Chittagong & Sylhet divisions with higher prevalence of child malnutrition – Rat-infested areas in the Hill Tracts

Recommendations • But the ultimate goal is to prevent/control rapid unplanned urbanization – Create livelihoods in rural Bangladesh – Control population growth drastically – Improve livelihood & living conditions of people who are already living in urban areas