Dr Tahmeed Ahmed Director Centre for Nutrition & Food Security ICDDR,B

1. 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

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

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

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

6. UNICEF; Black R, 2008

7. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 70 60 50 Percentage below -2SD NCHS/WHO Reference 40 30 20 10 2007 2004 1989-1990 1996-1997 1999-2000 Ahmed T et al. In press.

8. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 70 60 50 Percentage below -2SD NCHS/WHO Reference 40 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? 30 20 10 2007 2004 1989-1990 1996-1997 1999-2000 Ahmed T et al. In press.

9. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 70 60 50 Percentage below -2SD NCHS/WHO Reference 40 30 20 10 2007 2004 1989-1990 1996-1997 1999-2000 Ahmed T et al. In press.

10. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 70 60 50 Percentage below -2SD NCHS/WHO Reference 40 • 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 30 20 10 2007 2004 1989-1990 1996-1997 1999-2000 Ahmed T et al. In press.

11. Trends in Prevalence of Underweight in Under-5 Children in Bangladesh 80 70 60 50 Percentage below -2SD NCHS/WHO Reference 40 Required rate of reduction, 1.36 percent points/yr Rate of reduction so far, 1.27 percent points/yr 30 20 10 2015 2007 2004 1989-1990 1996-1997 1999-2000 Ahmed T et al. In press.

12. Malnutrition is more common in Asia than in Sub-Saharan Africa 60 47.8 47.0 50 44.9 38.5 40 35.6 NCHS/WHO Reference Percentage below -2SD 30 22.6 20.2 20 10 0 Nepal 2006 Uganda 2006 India 2005-06 Rwanda 2005 Ethiopia 2005 Cambodia 2005 Bangladesh 2007

13. Trends of BMI of Women in Bangladesh 60 52.0 50 45.4 40 34.3 29.7 Percent of women with BMI <18.5 30 20 10 0 1996-97 1999-2000 2004 2007

14. 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)

15. 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 India Indonesia China USA Nigeria Mexico Russia Brazil

16. Korail Slum

17. 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

18. 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

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

20. Food Security in Urban Slums Urban food security Atlas, 2008

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

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

23. Severe Acute Malnutrition • 2.9% in Bangladesh • ~500,000 children • At risk of death from • Hypoglycemia • Hypothermia • Infections

25. Admission 2 weeks • A 2 yr old girl with dysentery, pneumonia • Weighed only 3.8 kg • Treated with • therapeutic diets • antibiotics • micronutrients • Diagnosed TB and treated appropriately 4 weeks 5 weeks

26. Timeliness: Early Versus Late Presentation

28. There has been some improvement but much more is required

29. The Lancet Series on Maternal and Child Undernutrition

30. Evidence-Based Interventions Bhutta ZA, Ahmed T et al. Lancet 2008

31. 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

32. 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 Hygiene interventions: Reduce incidence of diarrhea by 30%, reduce odds of stunting • 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

33. Evidence-Based Interventions Bhutta ZA, Ahmed T et al. Lancet 2008

34. Coverage is most important ! Bhutta ZA, Ahmed T et al. Lancet 2008

35. 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.

36. 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

37. 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

38. 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

39. 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

40. 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