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 %
Zita Weise Prinzo
Evidence and Programme Guidance
Department of Nutrition for Health and Development
WHO Geneva
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
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.
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%
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.
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
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)
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.
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.
Long-term consequences
Concurrent problems & short-term consequences
Health
↑Mortality
↑Morbidities
Developmental
↓Cognitive, motor,
and language
development
Economic
↑Health
expenditures
↑Opportunity costs
for care of sick child
Health
↓Adult stature
↑Obesity and
associated comorbidities
↓ Reproductive
health
Developmental
↓School
performance
↓ Learning capacity
Unachieved potential
Economic
↓ Work capacity
↓ Work productivity
Consequences
PO1
Stunted Growth and Development
Causes
PR2: Water
PR3: Sanitation
Inadequate Complementary Feeding
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
Home environment
• Inadequate child
stimulation and activity
• Poor care practices
•Inadequate sanitation
and water supply
• Food insecurity
• Inappropriate intrahousehold food allocation
• Low caregiver education
Context
Poor quality foods
• Poor micronutrient
quality
• Low dietary diversity
and intake of animalsource foods
• Anti-nutrient content
• Low energy content of
complementary foods
Inadequate practices
• Infrequent feeding
• Inadequate feeding
during and after illness
• Thin food consistency
• Feeding insufficient
quantities
• Non-responsive feeding
Food and water safety
• Contaminated food and
water
• Poor hygiene practices
• Unsafe storage and
preparation of foods
IO1: malaria
IO2: Diarrhea
Breastfeeding
Infection
Inadequate practices
• Delayed initiation
• Non-exclusive
breastfeeding
• Early cessation of
breastfeeding
Clinical and subclinical
infection
• Enteric infection:
Diarrhoeal disease,
environmental
enteropathy, helminths
• Respiratory infections
• Malaria
• Reduced appetite due to
infection
• Inflammation
PR1: Adequacy
PR8: Diversity
PR6: dietary energy
PR10: HH exp on food
Community and societal factors
Political economy
• Food prices and trade policy
• Marketing regulations
• Political stability
• Poverty, income and wealth
• Financial services
• Employment and livelihoods
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)
Society and Culture
• Beliefs and norms
• Social support networks
• Child caregivers (parental
and non-parental)
• Women’s status
PR4: ITN; PR5: ORS
PR9: Immunization
Agriculture and Food Systems
• Food production and
processing
•Availability of micronutrientrich foods
• Food safety and quality
Water, Sanitation and
Environment
• Water and sanitation
infrastructure and services
• Population density
•Climate change
•Urbanization
• Natural and manmade
disasters
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)
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
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
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)
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
Process indicators
(see stunting)
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.
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
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)