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Dr Tahmeed Ahmed
Director Centre for Nutrition & Food Security ICDDR,B
Professor, Public Health NutritionJames P. Grant School of Public Health, BRAC University
Food & Nutrition Situation in Bangladesh
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Intergenerational Cycle of Malnutrition
Llanos, Alvear, Uauy 2004
ADULTS
Malnourished
AdolescentStunted
PregnancyLow Weight
Gain
ChildStunted
BabyLow Birth
Weight
Higher maternal mortality
Reduced mental
capacity
Reduced mental
capacity
Foetal Malnutrition
Higher mortality
rateImpaired mental
development
Untimely / inadequate weaning
Frequent infections
Inadequate food, health
& care
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Different Types of Childhood Malnutrition
Wasted
Low weight for height
Stunted
Low height for age
Underweight
Low weight for ageNormal
Normal height for age
Ch
ild
ren
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Stunting in Early Childhood & Later Development Outcomes
Mendez MA, 1999
46
48
50
52
54
56
58
Cognitive score at 8 y
Not stunted
Mildly stunted
Moderately/severely stunted
Philippines, n=2489
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UNICEF; Black R, 2008
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Trends in Prevalence of Underweight in Under-5 Children in Bangladesh
10
20
30
40
50
60
70
80
198
9-19
90
199
6-19
97
199
9-20
00
200
420
07
Per
cent
age
belo
w -
2SD
NC
HS
/WH
O R
efer
ence
Ahmed T et al. In press.
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Trends in Prevalence of Underweight in Under-5 Children in Bangladesh
10
20
30
40
50
60
70
80
198
9-19
90
199
6-19
97
199
9-20
00
200
420
07
Per
cent
age
belo
w -
2SD
NC
HS
/WH
O R
efer
ence
Reasons for the decline:
Increased literacy Fertility rate reduced
Measles vaccination now at 83% Family size smaller
Vitamin A supplementation coverage at 88% Rural electrification
Increased food production & energy intake Microcredit?
Ahmed T et al. In press.
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Trends in Prevalence of Underweight in Under-5 Children in Bangladesh
10
20
30
40
50
60
70
80
198
9-19
90
199
6-19
97
199
9-20
00
200
420
07
Per
cent
age
belo
w -
2SD
NC
HS
/WH
O R
efer
ence
Ahmed T et al. In press.
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Trends in Prevalence of Underweight in Under-5 Children in Bangladesh
10
20
30
40
50
60
70
80
198
9-19
90
199
6-19
97
199
9-20
00
200
420
07
Per
cent
age
belo
w -
2SD
NC
HS
/WH
O R
efer
ence
Assumptions on reasons for the stagnation:
•Increase in inequity (increase in Gini coefficient)
•Reduction in infant mortality rate resulting in more infants surviving but
with malnutrition
Ahmed T et al. In press.
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Trends in Prevalence of Underweight in Under-5 Children in Bangladesh
10
20
30
40
50
60
70
80
198
9-19
90
199
6-19
97
199
9-20
00
200
420
07
Per
cent
age
belo
w -
2SD
NC
HS
/WH
O R
efer
ence
2015
Required rate of reduction, 1.36 percent points/yr
Rate of reduction so far, 1.27 percent points/yr
Ahmed T et al. In press.
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Malnutrition is more common in Asia than in Sub-Saharan Africa
47.0 47.844.9
35.638.5
22.620.2
0
10
20
30
40
50
60
Bangla
desh 2
007
India
200
5-06
Nepal
200
6
Cambodia
200
5
Ethio
pia 2
005
Rwanda
2005
Uganda
2006
Pe
rcen
tag
e b
elo
w -
2SD
NC
HS
/WH
O R
efe
ren
ce
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Trends of BMI of Women in Bangladesh
52.0
45.4
34.329.7
0
10
20
30
40
50
60
1996-97 1999-2000 2004 2007
Pe
rce
nt
of
wo
me
n w
ith
BM
I <1
8.5
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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)
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0
200
400
600
800
1000
1200
0 200 400 600 800 1000 1200 1400
Population (millions)
Pop
ulat
ion
Den
sity
(/ s
q.km
.)
Bangladesh
Japan
Pakistan
Nigeria
Indonesia
Mexico Russia Brazil
USA China
India
Population density in Bangladesh is 3 to 40
times higher than other ‘mega’ countries
Limited Land Mass with the HighestPopulation Density
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Korail Slum
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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
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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
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BBS, World Bank, WFP 2005
•Poverty•Food insecurity•Poor maternal nutrition•Low birth weight•Low rates of EBF•Lack of proper CF•Frequent illnesses
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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
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Howarth Bouis, 2006
Share of Energy Intake in Bangladesh
Staples
Non-stapleplants
Fish andanimal
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- Carbohydrates in diet- ‘Fast food’ culture- Lack of exercise
Slum Non-slumUnderweight (BMI <18.5) 26.7 12.9
Over weight (BMI ≥25) 14.8 34.2
Diabetes mellitus 5.5 17.0
Hypertension 12.1 21.4
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Severe Acute Malnutrition
2.9% in Bangladesh~500,000 children
At risk of death from
• Hypoglycemia• Hypothermia• Infections
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A 2 yr old girl with dysentery, pneumonia
Weighed only 3.8 kg
Treated with• therapeutic diets• antibiotics• micronutrients
Diagnosed TB and treated appropriately
Admission 2 weeks
4 weeks 5 weeks
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Timeliness: Early Versus Late Presentation
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There has been some improvement but much more is required
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The Lancet Series on Maternal and Child Undernutrition
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Evidence-Based Interventions
Bhutta ZA, Ahmed T et al. Lancet 2008
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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
• Promotion of breastfeeding (individual and group counseling)
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
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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
• Promotion of breastfeeding (individual and group counseling)
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
Hygiene interventions: Reduce incidence of diarrhea by 30%, reduce odds of stunting
Bhutta ZA, Ahmed T et al. Lancet 2008
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Evidence-Based Interventions
Bhutta ZA, Ahmed T et al. Lancet 2008
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Coverage is most important !
Reduction in deaths
Reduction in stunting
% of DALYs averted
99% coverage 25% 35% 25%
90 % coverage 22% 32% 23%
70 % coverage 17% 27% 17%
Bhutta ZA, Ahmed T et al. Lancet 2008
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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.
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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
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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
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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
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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
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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