ACCELERATING THE

REDUCTION OF STUNTIG
IN ETHIOPIA

January/ 2014
What is Nutrition and Cause of malnutrition
What is stunting?
And
Why childhood stunting it matters?
What is Nutrition
 Nutrition is defined by WHO as a “process where by living
organisms utilize food for maintenance of life, growth and
normal functioning of organs and tissues and the production of
energy”
 Nutrition is also the provision of adequate energy and nutrients
 (in terms of amount and mix and timeliness)

Classification of Nutrients
 Carbohydrates
 Lipids or Fats
 Proteins
 Vitamins
 Minerals
 Water
 A. Malnutrition: Prevalence & trends
 Malnutrition
 Is undesirable physical or disease conditions which
 can be caused by eating :
 Too little,
 Too much or
 unbalanced diet that does not contain all nutrients

 Digestive or absorption problems or other medical

problems

 In this presentation the term malnutrition is restricted

 to: - Energy
Meet the body
- Protein
 under nutrition - MI.
requirements
◦ or nutrients
 lack of adequate:
 Causes of malnutrition
 There are a number of causes and they can all play a part in

contributing to malnutrition.

1. Immediate causes
 Inadequate food intake- such as not eating enough and/or correct
type of food, early/late weaning or stopping breast feeding early,

poor feeding practice due to lack of knowledge, etc…

 Infection – The four childhood killers which are common in emergency

settings – measles, malaria, diarrhoeal disease and acute respiratory

infections – may all contribute to malnutrition through causes loss of

appetite, nutrient losses through diarrhoea and vomiting. Person

needs to maintain febrile response using up stores and breaking down

fat and protein.

2. Underlying cases (at HH family level)
 Inadequate education
 Inadequate access to food (food insecurity)
 Inadequate care for mother and children
 Inadequate health services and unhealthy environment, etc…

3. Basic/root causes

o Basic/root causes depend on the political, ideological and
economic system of the country (good governance, economic
and development plans, grains and livestock production, trade
policies human rights including food and nutrition).
Determinants of Malnutrition

Note: One needs to consider the specific determinants

in a given area for effective IYCF intervention
 Classification of malnutrition

Malnutrition

Over
Under nutrition
nutrition

Chronic Acute
malnutrition malnutrition

Severe Acute Moderate acute

malnutrition malnutrition

SAM with SAM with out

medical medical Supplementary
complication complication feeding
In-patient
OTP
care
Major cause of deaths among Ethiopian chaldéen 0-5 year old

FMOH, 2008
Clinical manifestations of severe acute malnutrition

1. Marasmus
Features
• Old- man face
• Sticking out ribs
• Loose folded skin
• Wrinkled face
• Sunken eyes and wide awake appearance
2. Kwashiorkor
• Thin light hair, color of hair is pale, easily pluck able
• Swollen rounded face (moon face)
• Miserable expression (apathy)
• Oedema on hands, lower leg and feet
3. Miasmic Kwashiorkor
• has both nutritional marasmus and kwashiorkor features

• Severe wasting

• Poor growth

• Absence of subcutaneous fat

• Presence of bilateral Oedema

 There are three primary anthropometric indices for children under five years of age: Wasting;

Stunting, and Underweight.

Indicators What it measures/What it is used for

Low weight-for-  WASTING (acute malnutrition):-that

height reflects short term growth failure
 Recent or continuing , severe rapid wt. Loss and low
MUAC, or nutritional oedema

Low weight-for-  UNDERWEIGHT (acute or chronic

age malnutrition, or both):- that reflects a
combination of both chronic and acute growth failure

Low height for STUNTING (chronic malnutrition) reflects longer term

growth failure
his age
 Insufficient height gain in relation to age
 What is stunting
 Stunting is what happens to a child’s brain and body
when they don’t get the right kind of food or nutrients in
their first 1,000 days of life.
 Stunted growth is a reduced growth rate in human
development. It is a primary manifestation of malnutrition

in early childhood, including malnutrition during fetal

development brought on by the malnourished mother.

 According to the latest UN estimates, an estimated 165
million children under 5 years of age, or 26%, were
stunted in 2011.
 More than 90% of the world's stunted children live in
Africa and Asia, where 36% respectively 27% of
children are affected.
 Once established, stunting and its effects typically
become permanent.
 Stunted children may never regain the height lost as
a result of stunting, and most children will never
gain the corresponding body weight.
 It also leads to premature death later in life because
vital organs never fully develop during childhood
 A stunted child is often inches shorter than a
child who's had enough of the right kind of
food.
 Their immune system is weaker, leaving them
more vulnerable to disease. They're five times
more likely to die from diarrhoea.
 Under-nutrition is the underlying cause of 3.5
million preventable maternal and child deaths
each year.
 It is also responsible for 35 per cent of the
disease burden in children under the age of five
165 million children under 5 are stunted

Source: WHO Global Database on Child Growth and Malnutrition, May 2009
Stunting prevalence & number affected in developing countries

The prevalence of stunting is the The largest number of stunted

highest in Africa >40% children is in Asia ( 112 million)
50

200
48.6

190

40.3
40

39.3
37.7 38.2

150
Number of stunted (millions)
138
30
Stunting (%)

27.6

100
23.7 100
20

18.1

60
13.5
51

50
45
10

13
10
7
0

0
1990 2000 2010 1990 2000 2010

Source: Department of Nutrition, World Health Organization AFRICA ASIA LATIN AMERICA
 Prevalence of stunting in
children(2005)
60

50 47

40

30

20

10

0
prevalence of stunting and in Ethiopia and finding of key IYCF
indicators from DHS 2011 report

Key IYCF
indicators Amhara Oromia SNNPR Tigray Ethiopia
Stunting 52 41.4 44.4 51.4 44

Under weight 33.4 26 28.3 35.1 29

Wasting 9.9 9.7 7.6 10.3 10

 The percentage of children who are stunted is 44 percent; of
which 21 percent are severely stunted

 10 percent of children are wasted

 29 percent of all children are underweight and 9 percent of

children are severely underweight
Trends in Nutritional Status of Children
Under Age 5 EDHS(2000-2011)

70
60 58

50 47 44
41
Percentage

40 33
29 2000
30
2005
20
12 12 10 2011
10
0
Stunting Wasting Underweight
Anthropometric Indicators
 WHO Growth Standards
 Growth potential: Children throughout the
 world can attain growth potential if nurtured
in healthy
 environments and caregivers follow :
 Recommended health care
 Nutrition ( optimum child feeding )
 Child care practices ( HH & community)
 Population based studies: Average height
 of children from birth to 5 years was nearly
 identical across 6 populations:

Brazil, Ghana, India,
 Norway, Different SES
 Oman & the US)
Main causes of stunting

1. Inadequate food: to support the fast growth and

development of children

2. Infection: Frequent infection during early life

3. IUGR: Intrauterine growth retardation

Stunting
Affects one-third of children under 5 yrs. In low &
middle income countries
 Prevalence of stunting the highest in Africa 40%
B. Why is stunting more worrying

 Unnoticed: in health facilities, households

& communities

 No priority focus: Most of the exiting

nutrition intervention focused on Acute
malnutrition (e.g. SAM)

 Lack of recognition: Lack of recognition

that interventions to address stunting can
address all form of malnutrition
 Affects larger populations
Pictorial seen of stunting
2 yrs, 2 4 yrs, 4 mos Invisible: It is invisible, hard to
mos
detect & mostly overlooked

Intergenerational: Although
it occurs in uterine and early
childhood, its effect persists for
life time
3. Why Stunting matters?

 Damage suffered in early life leads to

permanent damage
 Reduced immune response

 Reduced adult size

 Reduced intellectual ability

 Lower economic productivity

 Poorer reproductive outcomes

Stunting
 Poorer mental performance
 Delayed school entry
 Lower school performance
 Greater grade repetition
 Increased school drop out

same age
World map showing % of children under height for age
 Pictorial seen of wasting

Marasmus (gross wasting))

Kwashiorkor (Oedema)
Under nutrition as a life cycle process
 Malnutrition affects the MDGs ( 6/8)

MDG Description
Goal 1  Malnutrition erodes human capital
Eradicate extreme
 Addressing early child malnutrition can
poverty & hunger
prohibit shocks & increase productivity
Goal 2  Malnutrition reduces mental capacity
Achieve universal
 Micronutrients ( iodine, vit. A, iron, zinc, ..)
primary education
are critical for cognitive development
Goal 3 Malnutrition increases the child care
Promote gender burden for women
equality & empower
 Better nourished girls are more likely to stay in
women
school and to have more control over
future choices
Goal 4:  Malnutrition is associated with more than 50%
of child deaths
Reduce child  Breastfeeding + complementary (and later)
 Malnutrition affects the MDGs ( 6/8) con….

Goal 5:  Malnutrition compromises maternal health

Improve maternal  Micronutrients ( e.g.. Folate, iron..)help

health reduce
pregnancy complications and improve the
health of newborns
Goal 6:
Nutritional status affects susceptibility to HIV
Combating infection
HIV/AIDS, malaria,
and other diseases  Improved nutrition may delay progression to
AIDS
 Window of opportunity: Whom to target to
prevent malnutrition in IYC?
 Preconception
through pregnancy  0-6 mo: Exclusive  6-24 mo:
breastfeeding Complementary
feeding

Sources:
http://www.marieclaire.com/cm/marieclaire/images/mcx0807FEI
ndia001-med.jpg
;
http://www.who.int/child_adolescent_health/documents/media/9
241593431.jpg
Why is the period of 6-24 months so critical?

 Age of greatest vulnerability to malnutrition and

infection

 Potentially irreversible long-term physical and

mental damage
Possible ways to address malnutrition

• Balanced diet  promote good dietary diversity

• Micronutrient supplementation and deworming

• Behaviour change communication/ nutrition

education

 Also:
◦ Addressing child disease burden
◦ Improving food security Improving water,
sanitation and hygiene situation
Focused IYCF Interventions

 Early initiation of Breast Feeding

within 1hr of birth, including
provision of first milk

 Exclusive Breast Feeding during

the first six month of life,
Focused IYCF Interventions

 Timely initiation of appropriate

complementary feeding, while
continuing breast feeding till 2yrs of
age and beyond,

 Appropriate feeding practice of the

sick child during and after illness,
along with proper medical care
Evidence - based interventions
 Interventions showing the most promise for
reducing child deaths and future disease
burden include:
 Bf promotion
 Appropriate comp feeding
 Supplementation with vitamin A and zinc
 Appropriate management of severe acute
malnutrition
Conclusion

 Stunting needs to be addressed because it

strongly affects later outcomes

 Efforts to prevent stunting will likely have

multiple benefits

 Conception through 24 months is the critical

window of opportunity to prevent and intervene
to reduce stunting
Many Thanks!!
Definition
 Neonate :- A new born baby, specifically a baby in the
first 4 weeks after birth. After a month,
a baby is no longer considered a neonate
 Infant:- A young baby, from birth to 12 months of
age

 Definition of ADOLESCENCE:- the period of life from

puberty to maturity terminating legally
at the age of majority