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 Foetal Malnutrition Untimely / inadequate weaning Frequent infections Inadequate food, health & care Child Stunted Malnourished ADULTS Pregnancy Low Weight Gain Adolescent Stunted Reduced mental capacity Higher maternal mortality Reduced mental capacity

Llanos, Alvear, Uauy 2004

Different Types of Childhood Malnutrition

Normal height for age

Normal Wasted

Low weight for height

Stunted

Low height for age

Underweight

Low weight for age

58 56 54 52 50 48 Stunting in Early Childhood & Later Development Outcomes

Philippines, n=2489 Not stunted Mildly stunted Moderately/severely stunted

46 Cognitive score at 8 y

Mendez MA, 1999

UNICEF; Black R, 2008

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

80 70 60 50 40 30 20 10

Ahmed T et al. In press.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

80 70 60 50 40 30

Measles vaccination now at 83% Vitamin A supplementation coverage at 88% Increased food production & energy intake Fertility rate reduced Family size smaller Rural electrification Microcredit?

Ahmed T et al. In press.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

80 70 60 50 40 30 20 10

Ahmed T et al. In press.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

80 70 60 50 40 30

• Reduction in infant mortality rate resulting in more infants surviving but with malnutrition Ahmed T et al. In press.

Trends in Prevalence of Underweight in Under-5 Children in Bangladesh

80 70 60 50 40 30 20 10

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.

Malnutrition is more common in Asia than in Sub-Saharan Africa

60 50 47.0

47.8

44.9

38.5

40 35.6

30 22.6

20.2

20 10 0

Trends of BMI of Women in Bangladesh

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

1200 1000 800 600 400 200 Nigeria 0 0 Mexico 200 Russia Bangladesh Japan Pakistan Indonesia USA 400 Brazil 600 Population density in Bangladesh is 3 to 40 times higher than other ‘mega’ countries 800 Population (millions) China 1000 1200 India 1400

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

<2,122 kcal/person/d

Dhaka

42.4

<1,805 kcal/person/d 24.2

Chittagong Khulna Rajshahi All

56.0

35.8

52.0

38.5

61.3

36.0

47.8

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

Slum

26.7

14.8

5.5

12.1

Non-slum

12.9

34.2

17.0

21.4

- Carbohydrates in diet ‘Fast food’ culture - Lack of exercise

Severe Acute Malnutrition

2.9% in Bangladesh ~500,000 children

At risk of death from

• Hypoglycemia • Hypothermia • Infections

Admission 4 weeks 2 weeks

A 2 yr old girl with dysentery, pneumonia Weighed only 3.8 kg

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 severe acute malnutrition 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 • 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

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

Hygiene interventions:

supplementation improved complementary feeding • Zinc supplementation • Zinc in management of

Reduce incidence of diarrhea by 30%,

• Vitamin A fortification 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 supplementation • Universal salt iodization • Handwashing or hygiene interventions •Treatment of SAM Bhutta ZA, Ahmed T et al. Lancet 2008

Evidence-Based Interventions

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 !

99% coverage Reduction in deaths Reduction in stunting 25% 35% % of DALYs averted 25% 90 % coverage 70 % coverage 22% 17% 32% 27% 23% 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