Social transfer pilot to improve nutrition outcomes in Nepal. Evidence review of food products appropriate to achieve improved birth weight in Nepal:

Transcription

1 Social transfer pilot to improve nutrition outcomes in Nepal Evidence review of food products appropriate to achieve improved birth weight in Nepal: Final version Prepared by: LM Neufeld, PhD November 28, 2011

2 Table of Contents Acronyms and abbreviations List of Tables List of Figures List of Boxes Executive summary 5 1. Presentation 8 2. Methodology for the literature review and formulation of recommendations 8 3. Background: food security, health and nutrition in Nepal 3.1 Socio-demographic and health profile of women in Nepal 3.2 Food availability and food insecurity in Nepal 3.3 Existing nutritional supplements and special foods in Nepal 4. Nutritional status of women of childbearing age and pregnant women in Nepal 4.1 Indicators used to assess nutritional status 4.2 Nutritional status of women in Nepal 4.3 Risk factors for malnutrition in Nepali women 5. Evidence of the efficacy and effectiveness of nutritional supplements and special foods to improve pregnant outcomes 5.1 Energy and protein supplements with or without other nutrients Evidence from systematic reviews of randomized controlled trials Evidence from recent studies not included in the systematic reviews Evidence of the acceptance and utilization of balanced energy-protein foods targeted to pregnant and lactating women 5.2 Supplements with long-chain polyunsaturated fatty acids (LC-PUFA) Evidence from systematic reviews of randomized controlled trials Evidence from recent studies not included in the systematic reviews Evidence of the acceptance and utilization of LC-PUFA supplements targeted to pregnant and lactating women 5.3 Micronutrients supplements Evidence from systematic reviews of randomized controlled trials Evidence from recent studies not included in the systematic reviews Evidence of the acceptance and utilization of micronutrient supplements targeted to pregnant and lactating women 5.4 Fortified foods compared with unfortified foods with similar macronutrient content, including micronutrient powders for home fortification Evidence from systematic reviews of randomized controlled trials Evidence from recent studies not included in the systematic reviews Evidence of the acceptance and utilization of fortified foods and micronutrient powders targeted to pregnant and lactating women 6 Discussion of the evidence review for food products recommendations 6.1 Evidence of unmet nutritional needs in Nepal 6.2 Evidence of supplement efficacy and effectiveness 6.3 Evidence of factors that could influence program success 6.4 Evidence to support the specific nutrient content of the supplementary food 7 Recommendations for the food to be used in the social protection trial in Nepal 33 References 35 ii iii iv iv iv

3 Acronyms and abbreviations BMI CSB FAO IFA IUGR IMNMP LCPUFA LBW LiST LNS MI MMN MNP mo NDHS NGO PEM RCT RDA RUTF SGA VAD WFP WHO WSB Body Mass Index Corn-soy blend Food and Agriculture Organization of the United Nations Iron folic acid supplementation Intra uterine growth retardation Intensification of Maternal and Neonatal Micronutrient Program Long chain poly unsaturated fatty acids Low birthweight Lives Saved Tool Lipid based nutrient supplement Micronutrient Initiative Multiple micronutrient supplements Micronutrient powders Months Nepal Demographic Health Survey Non-governmental organizations Protein energy malnutrition Randomized control trial Recommended Dietary Allowance Ready-to-use therapeutic food Small for gestational age Vitamin A deficiency World Food Programme World Health Organization Wheat-soya blend iii

4 List of Tables Table 1 Maternal mortality and indicators of antenatal and delivery care in the Terai, Mountain and Hill regions of Nepal 11 Table 2 Morbidity among children less than 5 years of age in Nepal (2006) 12 Table 3 Food availability in Nepal ( ) 13 Table 5 Nutritional status of women of childbearing age (n=10 730) in Nepal (2006) 17 Table 6 Prevalence of anemia among women of reproductive age (pregnant and non-pregnant combined) in Nepal (2011) 18 Table 7 Consumption of iron and vitamin A rich foods among women of childbearing age in Nepal (2006) 18 Table 8 Proposed nutrient content to be considered in the selection of the protein-energy balanced, micronutrient fortified food for use in Nepal 34 List of Figures Figure 1 Intergenerational cycle of growth failure 20 List of Boxes Box 1 Summary of nutritional problems in women of childbearing age in Nepal 21 iv

5 Executive summary The present consultancy is meant to support the World Bank and DFID in selecting a food product to improve birth weight in women participating in a social transfer study in the Terai region of Nepal. Scientific databases and grey literature were searched through Pubmed, Scielo, LILACS, and Google Scholar and additional papers were found through cross referencing. The information was used to provide evidence of unmet nutritional needs among pregnant women in Nepal, evidence of the efficacy and effectiveness of different nutritional supplements to improve fetal growth and maternal nutritional status and evidence of multiple factors that might favor program success including acceptance and regular utilization of nutritional supplements and potential for economic viability and sustainability of a supplementation program and evidence that would support the selection of an individual food or the content of such a food for the study in Nepal. The review presented here is not a systematic review in the sense that formal processes such as those outlined by Cochrane were not used. We have however, conducted an exhaustive search to find all studies and meta-analyses or other reviews of evidence of supplementation impact on fetal growth and specifically birth weight. Further meta-analysis or other statistical methods to estimate a pooled effect of supplementation on birth weight were not carried out. Rather, given that the purpose of the review is to identify foods that could potentially be utilized in the study, we focus on a number of considerations beyond just impact on birth weight, such as factors that might facilitate regular consumption. The review of the information available on the nutritional needs of women in Nepal revealed the following. A high proportion of women likely suffered from nutritional stunting during early life. There is no clear difference in the prevalence or severity of this problem among the three regions of the country. Although recent data are scarce, based on the prevalence of anemia y smaller studies in specific regions of the country including the Terai, deficiency of multiple micronutrients is highly prevalent among women. Based on the prevalence of anemia only, it would appear that the women in the Terai region may be particularly vulnerable to micronutrient malnutrition. The high prevalence of low body mass index reflects current insufficient food intake among a high proportion of women. Women in the Terai region are particularly vulnerable. Very little information is available to adequately document the determinants of low weight in women, but there is some evidence that intra-household allocation of food may influence women s nutritional status in the region. Based on the critical review of the literature, there is evidence to suggest that a balanced protein/energy food, fortified with multiple micronutrients would have high potential to improve fetal growth. Given some basic criteria for nutrient content, there is no evidence to suggest that one specific food is superior to another, nor is there evidence to suggest that the addition of longchain polyunsaturated fatty acids or other essential fats would provide additional benefit over and above what can be achieved from balanced protein/energy foods. Evidence does suggest, however that to be effective, the foods must be consumed on a regular basis and provide a net contribution to total energy and nutrient consumption in the day (i.e., not just displace regular home foods). Furthermore, given the high risk of intestinal parasites in the Terai region, the bidders should consider the possibility of linking with de-worming programs, according to appropriate practice during pregnancy. Based on the review, we recommend that the food have the following characteristics: 5

6 Balanced in energy and protein: Evidence from efficacy trials summarized in recent systematic reviews suggests that to improve birth weight, foods provided to pregnant women should be balanced in energy and protein, providing <25% of total energy from protein and include a source of high quality protein (nuts, seeds, fish or other animal source protein, or a combination of grains and legumes). Considering the evidence that a high proportion of women in the Terai region of Nepal are very thin, the total energy consumed by the women from the supplementary food should cover, at a minimum the estimated additional energy cost of pregnancy. According to the Institute of Medicine additional energy requirements to support pregnancy are higher in the second and third trimester, estimated to be 0, 340, and 452 kcal/day, in the first, second and third trimesters, respectively. The energy requirements of lactation are higher than that of pregnancy and higher in the first 6 mo postpartum than later. During the first 6 mo post partum, the energy cost of lactation is estimated at 500 kcal/day, of which approximately 170 kcal/day may come from reserves in well nourished women. Mobilization of reserves is not expected to contribute to total energy during the second 6 mo, and additional energy requirements are estimated at 400 kcal/day. Evidence suggests that among under nourished women, not meeting the extra energy demands of pregnancy and lactation can cause worsening of malnutrition and reduced birthweight with successive pregnancies. Nutritional supplementation during pregnancy and lactation can ameliorate these effects 1, therefore we suggest that the nutritional supplementation should continue for the recommended period of exclusive breastfeeding (i.e., 6 mo postpartum). Fortified with micronutrients: Although still somewhat scarce, evidence suggests that fortified foods provide a number of benefits over and above otherwise similar non-fortified foods, if not for birth outcomes, then at least for maternal outcomes and possibly for the nutrient content of breast milk. The currently available evidence on micronutrient status of pregnant women in Nepal is very limited. Based on the older data, the high prevalence of anemia and the studies conducted on smaller samples in the Terai region, we conclude that it is likely that women are deficient in multiple micronutrients. Women may be particularly at risk for deficiency of micronutrients that are concentrated in animal source foods and in foods that are highly seasonal such as vitamin A, E, B6, B12, iron, zinc, among others. According to the latest World Health Organization (WHO) guideline, iron and folic acid supplementation (IFA) improve birth weight. Given that Nepal has a well-functioning IFA program for pregnant women fortification with these may not be required in the food supplement, but only if close attention if paid to ensure high coverage and compliance. There is also some evidence that multiple micronutrient supplements improve birthweight. The majority of supplementation trials (IFA and multiple micronutrients) have used doses of micronutrients (in supplements and foods) in the range of one recommended dietary allowance (RDA) per day. One such study from the Terai of Nepal showed that supplementation was insufficient to replete, and many remained deficient after supplementation. In one study from Africa, multiple micronutrient supplements with 2 RDA/day were more effective than lower doses to improve birth weight, particularly among anemic women. These results have not yet been replicated elsewhere. In summary, at this time there is some evidence that micronutrient content above 1 RDA may provide some additional benefit above lower doses for pregnancy outcome, particularly in populations with high prevalence of deficiency, but research is not yet sufficient to support any specific content. The food should be designed in such a way that women receive at a minimum 1 RDA of essential nutrients each day during the study; higher content (up to 2 RDA) could be suggested by the bidders but should be clearly justified with reference to relevant literature. 6

7 Optionally include long-chain polyunsaturated fatty acids (LC-PUFA): Although promising based on results of supplementation trials with LC-PUFAs in women from developed countries, there is no specific evidence at this time to determine whether the inclusion of LC-PUFA or other essential fats in balanced protein energy supplements for pregnant women confers benefits for the fetus and/or mother over and above those that would be expected from similar foods without them. Nor is there information available to determine the current level of intake of LC-PUFA s among pregnant women in Nepal. Specific recommendations for the food to be used in the supplementation trial in Nepal The evidence base does not provide a clearly unique choice of one food that fulfils all criteria laid out above better than any other. Multiple food types have been used in diverse settings and there is no clear pattern that would suggest that one food or food type is superior to another. For example, we reviewed the content of all foods included in the studies with positive and with no impact of fetal growth to determine whether a pattern existed as to the content of milk or other daily or animal source products; no such pattern was apparent. Nor is there any specific evidence that would guide a recommendation related to potential acceptance and regular utilization of the food by pregnant women in the Terai region of Nepal. Based on this assessment, we propose that a table of proposed nutrient content for the food is included in the terms of reference for the study design. The proposed content has been determined based on current recommendations of the energy and nutrient needs of pregnancy and previous trials of supplements that were found to be efficacious in improving fetal growth and maternal outcomes. We recommend that this content be considered a guide, and that the bidders would be free to propose an improved content, as long as any substantial modifications are clearly justified with reference to appropriate literature. For micronutrient content we recommend that the level be kept no lower than 1 RDA and no higher than 2; high levels should be supported by reference to the literature. We recommend that the intervention be kept as simple as possible and avoid the introduction of multiple new products that would require behavior changes for adoption. For example, we consider the use of a fortified food preferable to 2 products, such as an unfortified food and the use of a home fortificant of additional tablet as each would require effective behavior change for their adoption and appropriate utilization. Additional factors that must be taken into consideration for the food choice is evidence of acceptance and high potential for appropriate utilization by pregnant women in the proposed region of the Terai in Nepal. We recommend that the terms of reference for the bidders lay out clear instruction to include details in the proposal for plans for selection or development of the food, and the study or studies that they will conducted as part of the startup phase to document acceptance and potential for utilization, using appropriate qualitative research methodologies. If possible, the bidders should also provide some commentary on the potential for the food to be produced/ procured in Nepal in the longer term, if not already being done so. 7

8 1 Presentation Despite economic growth and improvements in health indicators in recent years, the nutritional status of women and children in Nepal and other countries in South Asia has shown little improvement. Nepal is a world leader in addressing micronutrient deficiencies (e.g. Vitamin A supplementation program for children 6 to 59 mo of age, iron supplementation to reduce anemia during pregnancy, salt iodization) but has yet to put in place effective programs at scale to address general malnutrition which manifests itself in low body mass index (BMI) for women, low birth weight, as well as underweight, stunting and wasting in children. The Nepal Health Sector Program II (NHSP II) recognizes the need for a more comprehensive response to malnutrition in women and children. The NHSP II partners have agreed to support the Government of Nepal in its efforts to respond to the nutrition challenges and this response includes a combination of scaling-up evidence-based interventions as well as pilots to test innovative approaches. One such area which requires testing is the use of social transfers in the form of food, food vouchers or cash with the specific aim of improving birth weight. The World Bank and DFID are planning a study in Nepal to evaluate the impact of 2 social transfer modalities (i.e. food or food vouchers and cash transfer) on birth weight and the incidence of low birth weight (less than 2500 grams). The hypothesis to be tested through this pilot is that social transfers in the form of a food (or food voucher) or a cash transfer combined with a strong behavior change communication strategy will increase access to nutritious food and improve nutrition-related behaviors and thus enable women and newborns to achieve better nutritional status, as reflected in improved birth weight and maternal nutrition. The present consultancy is meant to support the World Bank and DFID in selecting a food product to use in the social transfer study. The food should be appropriate to achieve the desired outcome, i.e. to improve birth weight. The specific objectives of the consultancy are to: Review current data relating to macro and micronutrient malnutrition during pregnancy in Nepal (to the extent that such information is available). Review available evidence relating to commercially-available foods (in Nepal or on the international market) which would be suitable as a dietary supplement for women during pregnancy that respond to the needs identified among Nepali women. Based on these findings, make specific recommendations on foods that could be considered by the design team, as well as recommendations on program factors such as minimum quantities to provide. Any food recommended should be described in detail, including composition, existing information on impact, cost, programmatic experience, etc. 2 Methodology for the literature review and formulation of recommendations The analysis was based on an extensive search and desk review of published and grey literature on 2 broad topics. First, the nutritional status of women of reproductive age and pregnant women in Nepal in order to document any potential macro and/or micronutrient deficiencies among these population groups that may influence fetal growth and/or birthweight. Second, a review of the evidence of the efficacy and effectiveness of any food and/or micronutrient supplements to improve fetal growth and/or birthweight implemented in Nepal and internationally, with particular emphasis in contexts similar to those identified in Nepal. 8

9 Scientific databases and grey literature were searched (June 2011) through Pubmed, Scielo, LILACS, and Goggle Scholar. The following keywords were used and identified articles further filtered for those with a focus on fetal growth and/or birthweight: Health OR nutrition OR food availability OR food security AND Nepal Women OR pregnant women OR pregnancy OR women of reproductive age Deficiency OR micronutrient OR micronutrient deficiencies OR low body mass index Fetal growth OR birthweight OR low birth weight Intervention OR food OR supplement OR dietary supplement OR nutrient Fortification OR fortified food OR lipid based OR corn soy blend OR multiple micronutrient OR Sprinkles For the description of the situation in Nepal, we sought to include national and sub-national surveys but complemented this with information from other study types (observational, randomized and non-randomized intervention trials, others) when survey information was limited or not available. For the review of the impact of nutritional supplements to improve birth weight we focused on randomized controlled trials (efficacy) and program evaluation (effectiveness) studies. Many older studies, particularly those of food supplementation, had been reviewed in systematic reviews and meta-analyses. When such reviews were available, we focused on a summary of the findings of those reviews and complemented this information with any additional studies not included in published subsequently and refer to the individual studies on occasion to highlight details related to the food supplements themselves. For the review of the evidence of impact of supplements on birth outcomes, studies were divided into 3 categories, according to the nutrients being tested for their impact on fetal growth: Protein-energy supplements: For studies that tested the impact of protein and energy on fetal growth most used a placebo or micronutrient supplement as comparison group. If a micronutrient supplement was used as control group, the study was included in this category only if there was no substantial difference in micronutrient content between the intervention and control group (i.e., that both groups received micronutrients and the protein/energy was the nutrient being tested). Long-chain polyunsaturated fatty acids: The control group for the studies included in this group was usually a placebo. Multiple micronutrient supplements: IFA supplementation has been shown to improve birth weight (Cochrane review, forthcoming) and coverage and utilization of IFA in Nepal is high and all women participants in the study should be receiving and utilizing IFA. We therefore include in this group, only studies testing the impact of tablets or capsules with multiple micronutrient (IFA in addition to other nutrients) compared to IFA only or placebo as control group. Also included in this group are fortified foods compared to unfortified foods with otherwise similar nutrient content (i.e., that the protein/energy content of the test and control foods did not differ, only the micronutrient content). The review presented here is not a systematic review in the sense that formal processes such as those outlined by Cochrane were not used. We have however conducted an exhaustive search to find all studies and meta-analyses or other reviews of evidence of supplementation impact on fetal 9

10 growth and specifically birth weight. Further meta-analysis or other statistical methods to estimate a pooled effect of supplementation on birth weight were not carried out. Rather, given that the purpose of the review is to identify foods that could potentially be utilized in the study, we focus on a number of considerations beyond just impact on birth weight. For example, we part from the assumption that to have an impact of fetal growth, the mother must consume an appropriate proportion of the supplement on a regular (preferably daily) basis. To understand the potential of any foods chosen to be successful in this respect, we have also included any additional information available, including information from studies using qualitative research methodologies to understand acceptance, utilization, intra-household sharing of foods and other factors that might favor or disfavor utilization of the food by the women on a regular basis. The basis for the final assessment of potential foods for the study in Nepal considered the following factors: Evidence of unmet need: Evidence of food insecurity, inadequate dietary intake and nutritional deficiencies in Nepali women living specifically in the Terai region and existing programs that may be implemented with potential to already cover this unmet need Evidence of supplement efficacy (effectiveness if available): Evidence of impact on birth weight, incidence of low birth weight or other measures of the adequacy of fetal growth from RCT s and high quality program evaluations, if available Evidence of potential program success: Factors that might improve acceptance and utilization of specific food supplements such as appropriateness for cultural context and program sustainability, for example, evidence of lower cost and potential for local production (even if not currently produced locally) among food products with similar efficacy Evidence to support the specific nutrient content of the supplement: Based on unmet nutritional need and supplement efficacy, critical analysis of minimum criteria for the nutritional content of a supplement, and identification of any such supplements used in efficacy or effectiveness trials After taking these points into consideration, the potential pros and cons of specific food types will be discussed and the final recommendations for supplement content and food type justified in the context of the evidence review. 3 Background: food security, health and nutrition in Nepal 3.1 Socio-demographic and health profile of women in Nepal Nepal has a population just over 23 million people. 2 Because of relatively high fertility in the past, a large proportion of Nepal s population (approximately 40%) is under 15 years of age, with 13% less than age five. There are 103 diverse ethnic/caste groups in Nepal, each with its own distinct language and culture. 3 Nepali is the official language of the country and is the mother tongue of about half of the population. The country is divided into three distinct ecological zones: Mountain, Hill and Terai (or plains). The Terai consists of agricultural land as well as some dense forest area, national parks, wildlife reserves, and conservations areas. 2 This area is the most fertile part of the country and while it constitutes only 23 percent of the total land area in Nepal, 48 percent of the population lives here. Because of its relatively flat terrain, transportation and communication facilities are more developed in this zone than in the other two zones of the country and this has attracted newly emerging industries. In the Terai, temperatures can go up to 44 Celsius in the 10

11 summer and fall to 1 Celsius in the winter. The social transfer pilot is being planned for the Terai region of the country and therefore the following review of the health situation will focus to the extent possible on that region, providing some comparisons of the situation with the Mountain and Hill areas. Life expectancy in Nepal is 63 years, but due to high maternal mortality it is lower for women than for men. 4 Morbidity and mortality rates are high, particularly maternal, infant and child. 5 According to the 2006 Nepal Demographic and Health Survey (NDHS) maternal mortality i accounts for 18% of all deaths to women age years. Perinatal mortality is significantly higher among women whose age at birth was under 20 years or years. The main causes of infant and child deaths are due to diarrhea because of contaminated water and food borne diseases, nutritional diseases, chest infections, other communicable diseases and accidents. 2 Safe Motherhood is a priority program for reducing the high maternal mortality rate since Table 1 shows maternal mortality and indicators of antenatal care by region in Nepal. In general, indicators of coverage and quality of prenatal care in the Terai are slightly better than the Mountain but poorer than the Hill region of the country. Twenty nine percent of pregnant women make four or more antenatal care visits during their entire pregnancy. Urban women (52%) are twice as likely as rural women (26%) to have received four or more antenatal visits. About one in four women (28%) made their first antenatal care visit before the fourth month of pregnancy. The median duration of pregnancy at the first antenatal care visit was 4.6 months (3.8 months in urban areas and 4.7 months in rural areas). For the purposes of this study it is notable that in the Terai region in 2006, on average 65.7% reported having taken iron tablets during their most recent pregnancy, highest than the other 2 regions of the country. No information is available on actual adherence and this data represents only any consumption vs. none. Table 1 Maternal mortality and indicators of antenatal and delivery care in the Terai, Mountain and Hill regions of Nepal* Region of the country Indicator Terai Mountain Hill Maternal mortality rate, per 1000 women ( ) 33 a Antenatal and delivery care (2006) Antenatal care from a doctor at birth, % Antenatal care from a nurse/midwife at birth, % Antenatal care from a health assistant at birth, % Took iron pills during last pregnancy, % Took intestinal parasite drugs during last pregnancy, % Blood pressure measured during last pregnancy, % Informed about signs of complications during last pregnancy, % Urine sample taken during last pregnancy, % Blood sample take during last pregnancy, % * Source: Nepal Demographic Health Survey a Women y age. Data available on national level only i Defined as any death that occurred during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy (Nepal Demographic Health Survey) 1 11

12 The under-5 mortality rate was 48 per 1,000 live births in 2009 and the infant (under-1 y of age) mortality rate was 39 per 1,000 live births. 6 Under-5 y of age morbidity is shown in Table 2. Children in the Terai district have lower prevalence of diarrhea, acute respiratory infections and fever than children from the Mountain and Hill regions, but the magnitude of these differences is very small. Boys are slightly more likely than girls to be fully immunized (85% versus 81%). 2 Birth order varies inversely with immunization coverage; 90% of first-born children have been fully immunized, compared with 70% of children of birth order six and above. In the Terai, 86% of children 6-59 months of age are fully immunized and 58.5% have anemia (<11.0 g/dl). 2 The prevalence of infants with low birthweight was 21% during the reporting period Eight-eight percent of the total population of Nepal and 87% of the rural population had access to an improved water supply in 2008, but only 31% of the total population and 27% of the rural population had access to improved sanitation. 7 Table 2 Morbidity among children less than 5 years of age in Nepal* (2006) % children with % children with ARI a fever % children with diarrhea Residence Urban Rural Age in months < 6 mo old mo old mo old mo old mo old mo old Ecological zone Mountain Hill Terai * In the last 2 weeks preceding the survey a Acute Respiratory Infections 3.2 Food availability and food insecurity in Nepal The information presented in this section has been compiled mainly from NGO and international organization reports, including the World Food Program s latest summary (August 2011). No scientific literature was found on this topic. The information presented is intended to give an idea of the food availability and food security situation in Nepal to help guide the analysis and selection of food products. Agriculture is the mainstay of the economy and industrial activity mainly involves the processing of agricultural produce including jute, sugarcane, tobacco, and grain. 2 Trade liberalization was extensive during the 1980s and 1990s and has been associated with some improvement in 12

13 indicators of well being (i.e. indicators of food sufficiency and security like per capita food availability, per capita nutrient availability, and extent of malnourishment). 8 These benefits have been shared unevenly across different regions, with the most benefit in the Terai, due to better market facilities and infrastructure. 2 Food availability and food insecurity indicators in Nepal according to FAO 9 are shown in Table 3. Unfortunately the available data do not include all staple food products such as lentils. There has been concern that food production may have declined as a result of the conflict in the past decades and diminished access to land and other farm inputs (labor, fertilizer, manures, etc.), along with internal displacement and involuntary migration. 10 Ongoing political instability combined with frequent droughts and floods and sustained high food price inflation have compounded endemic factors, leading to increased vulnerability to food insecurity in the country. 11 According to FAO data, Nepal had a food deficit of 220 kcal per person per day during the 2005 to 2007 period. The Nepali diet is comprised principally of carbohydrates and there is little animal protein. Lentil is the major grain legume crop in Nepal and is the cheapest source of protein for poor and middle income families 12, and FAO reports mention lentils as a major import crop. Other major food commodities imports include milled rice, palm oil, soybean oil, and apples. Although useful to understand national food supplies and guide agricultural policy, it is important to remember that the FAO statistics do not provide information on the proportion of the population at risk of food insecurity or help to identify at-risk groups within the country. 13 Table 3 Food availability in Nepal a ( ) Food needs Minimum dietary energy requirement, kcal/person/day 1720 Average dietary energy requirement, kcal/person/day 2160 Food supply for human consumption Dietary energy supply, kcal/person/day 2350 Total protein, g/person/day 60.3 Animal protein, g/person/day 9.0 Fat, g/person/day 40.2 Major food commodities (share of dietary energy supply) Rice (milled), % 32.1 Maize flour, % 17.6 Wheat flour, % 14.7 Potatoes, % 4.2 Millet flour, % 3.5 Cereals, roots and tubers, % 73.5 Oils and fats, % 7.7 Ratio of production to consumption by major commodity Rice (milled), % Flour of maize, % Flour of wheat, % Potatoes, % Flour of millet, % a. Includes all foods with information available from FAO. Some staple items, such as lentils were not included in the reference. 13

14 From 2002 to 2009 the number of beneficiaries of food distribution and food assistance programs increased to almost 2 million people, mainly due to flooding, conflict, high food prices, and/or displaced populations. 14 From 2005 to 2007, food aid contributed 16.6% of the total dietary energy supply of the country. 9 Per capita food production in the Terai is nearly 50% higher than in the Hill and two times higher than in the Mountain regions. 8 There are per capita food deficits, especially in the mountains and in the hills. Policies geared to ensuring efficient means of food distribution as well as production are urgently required. 8 Unfortunately, no information was found that systematically analyses food insecurity at the household level in Nepal. One study documented evidence of gender differences in dietary intake of adults in the Terai region. The authors concluded that the gender differences in intra-household distribution of food contributed to the lower nutrient particularly iron intake among women. 15 The problem of food insecurity and insufficient regular consumption of micronutrient rich foods is well recognized in Nepal and a number of NGOs have implemented programs designed to combat these problems. For example, Chemonics International has been working with rural Nepalese households to produce and consume micronutrient rich, particularly vitamin A rich foods in kitchen gardens. 16 The Nepal Food Security Monitoring System, a joint activity of the Ministry of Agriculture and Cooperation and the World Food Program, generates and regularly (approximately once yearly) disseminates summary indicators of food security in the country overall and by 8 regions. 17 Food security is assessed using a composite indicator based on wealth quartile and food consumption, categorized as poor, borderline and adequate, resulting in 3 categories: Food Insecure, At Risk and Food Secure. According to the latest data (August 2011), the Terai region is generally food secure although approximately 30,000 households, 4.3% of the district population, were considered during the reporting period (April to June 2011) to be highly food insecure. A review of the reports over the past few years reveals that the trend towards general food security in the Terai region has existed for a number of years, whereas the hill and mountain region are still subject to greater variation in food security year to year and across seasons. As part of the same monitoring system, food prices of staple crops are monitored. Compared to 2009, food prices for rice, wheat flour, and black gram have increased substantially although others such as potatoes, lentils and oil have fluctuated somewhat without substantial increases. Overall, rising food prices remain a concern in Nepal. According to the latest report, year to year inflation (the Consumer Price Index) rose by 8.8% in June 2011, where as the index for cereal products rose 10.4%. 17 The rising prices, pockets of food insecurity remain a concern in Nepal, although the situation appears more stable in the Terai than Mountain and Hill regions. It is important to note that given the dynamics of food distribution within households, individuals could be food insecure despite overall household food security. The indicators used by the Nepali monitoring system reflects household purchases of specific food groups (staples, fruits and vegetables, oils among others) and cannot be used to assess distribution of the foods among household members. 3.3 Existing nutritional supplements and special foods in Nepal Initiatives have been underway for more than three decades with national nutritional strategies developed in 1978 (National Nutrition Strategy), 1986 (National Nutrition Strategy for Nepal), and 1998 (Nepal National Plan of Action). 2 Several programs with an explicit nutrition component have been launched in Nepal under the initiative of the Nutrition Section of the Ministry of Health and 14

15 Population. It was in that a National Nutrition Policy and Strategy was compiled and approved, which provided a comprehensive nutrition policy and strategy. 18 The major partners in initiating programs to address the problem of malnutrition are the United Mission to Nepal, World Food Program (WFP), Save the Children Alliance, and USAID. Additionally, UNICEF-Nepal and the Micronutrient Initiative (MI) have also played important roles. 2 In order to address the problem of anemia in women, the Intensification of Maternal and Neonatal Micronutrient Program (IMNMP) has been in place since 2003 as part of the Ministry of Health and Population s Nutrition Program, covering all 75 districts. The program involved distributing iron folic acid (IFA, 60 mg of elemental iron and 400 µg folic acid) supplements to all pregnant women free of charge. 2 The IFA tablets are provided to all pregnant women from the beginning of the second trimester of pregnancy and are continued for up to 45 days postpartum (225 days total). 2 Supplements are distributed by female community health volunteers who are trained and equipped to provide IFA tablets to pregnant and postnatal women at the community level and council for their appropriate utilization. 19 The association of hookworm infestation with pregnancy anemia is well recognized and the prevalence of hookworm is considered high in Nepal. The government has recently integrated training on deworming of pregnant women into the existing IMNMP program. 19 The 2006 Nepal Demographic Health Survey found that one in five women receives deworming tablets during their previous pregnancy. 2 There are also some special foods in Nepal being distributed by the WFP. These foods are assisting 547,300 food insecure and vulnerable people in Nepal through its Country Program, focusing particularly on the Western Mountainous regions. 20 First, fortified biscuits are distributed through the School Meals Programme, in remote and very vulnerable regions. 20 The serving size used is 100 g per person per day and provides 450 kcal per person per day. On a pilot basis, fortified biscuits will respond to a lack of cooking facilities and the overburdening of teachers, who sometimes have to take time away from their teaching responsibilities to prepare food. If the pilot proves successful, fortified biscuits could be used in the Government s futures school feeding strategy. 20 Second, wheat-soya blend (WSB) with an improved micronutrient fortified formula is also distributed by the School Meals Programme and by the mother-and-child health care. The serving of WSB for the School Meals Programme is 100 g per person per day. It is prepared with 10 g per person per day of vegetable ghee and provides a total of 463 kcal per person per day. 20 The serving of WSB for children 6 to 36 months of age through the health care is 7 kg per child per month and provides a total of 933 kcal per child per day. The serving size of WSB for pregnant and lactating women is 7 kg per person per month. It is prepared with one sachet of micronutrient powder per person per day and provides 933 kcal per person per day as well. 20 Information on micronutrient content of each preparation was not available at the moment. 4 Nutritional status of women of childbearing age and pregnant women in Nepal 4.1 Indicators used to assess nutritional status Multiple indicators can be used to assess nutritional status of adult women before, during and after pregnancy. For the purpose of the review included here, we have included 3 indicators, reflective of the adequacy of weight, height and micronutrient status of women. 15

16 Low weight at conception and poor pregnancy weight gain are important and independent risk factors for poor fetal growth and low birth weight. 21 Pre-pregnancy body mass index (BMI, weight in kilograms divided by the square of the height in meters) is a good indicator of current weight status, predicts women at risk of having a low birthweight baby and provides a framework for weight gain requirements during pregnancy. Women with low pre-pregnancy weight should gain more than those with adequate pre-pregnancy weight to ensure their own health and that of the developing fetus. 22 BMI is an internationally accepted indicator of body volume and is relatively unbiased by height. 23 A cutoff point in BMI of 18.5 is used to define thinness or acute under nutrition, and a BMI of 25 or above indicates overweight ( ) or obesity ( 30.0). According to WHO, a prevalence of more than 20% of women with a BMI less than 18.5 indicates a serious public health problem. Extremely short stature (<145 cm) is a reflection of poor nutritional status during childhood and in women, is associated with an elevated risk for complications at delivery due to small pelvis size and the potential for obstructed labor. Given the risks for the fetus, women of extremely short status should not seek to limit fetal growth (for example by under eating during pregnancy) but rather, should deliver with a skilled birth attendant (preferable in a health facility) to ensure that any potential difficulties during labor and delivery can be adequately managed. Micronutrient status can be assessed using measures of dietary intake or biomarkers of micronutrients status, usually in blood or urine. 23 The most relevant micronutrients during pregnancy due to elevated requirements and their known association with adverse effects both for mother and fetus are iron, vitamin A, calcium, folate, iodine, and vitamin B12 although many other essential nutrients may also be deficient. Micronutrient deficiencies are the result of inadequate intake of micronutrient-rich foods and/or the inadequate utilization and/or increased requirements of available micronutrients in the diet as a result of infections, parasitic infestations, and other factors. Multiple micronutrient deficiencies may be present in women during pregnancy given elevated needs and diets often low in a number of essential nutrients. Although not specific to deficiency, the most common indicator for assessment micronutrient status during pregnancy is anemia (low hemoglobin concentration). This is partly due to the deleterious effects of anemia on women and infants regardless of its cause as well as the ease of diagnosis compared to individual micronutrient deficiencies. 4.2 Nutritional status of women in Nepal At a national level, the percentage of women with BMI less than 18.5 is still over 20%, indicating that malnutrition in women is still a public heath priority in the country (Table 5). The prevalence decreased only 4 percentage points in the past decade, from 28% in 1996 to 24% in Women in rural areas (26%) and in the Terai region (32.7%) are at highest risk, with a particularly high percentage in the Central and Far-western Terai (37%) (data not shown). 2 Interesting, it is only in the highest economic quintile that any reduction in the prevalence of low weight is observed. No nationally representative data are available after Approximately 14% of Nepali women have extremely low height. 16

17 Table 5 Nutritional status of women of childbearing age (n= ) in Nepal (2006) Thinness Overweight/Obese Height BMI Total Mildly Moderately Total Overweight Obese <145 cm (%) normal ( ) (%) thin (BMI <18.5) (%) thin (BMI ) (%) and severely thin (BMI <17) (%) overweight or obese (BMI 25) (%) (BMI ) (%) (BMI 30) (%) Age y y y y Residence Urban Rural Ecological zone Mountain Hill Terai Wealth quintile Lowest Second Middle Fourth Highest According to 2011 DHS data, approximately one of every three women in Nepal suffers from anemia (Table 6). 24 The prevalence of anemia is approximately 15 percentage points higher in the Terai region than the Mountain or Hill region and only slightly higher in rural (35.8%) than urban (27.8%) regions. Although there is also variability by economic status and age, the prevalence is over 30% in all age groups. Information is also presented by wealth quintile but using data from 2006 as this information has not yet been released for Nationally representative data are also available for the risk of iron and vitamin A deficiency, based on reported consumption of nutrient rich foods (Table 7). More than three in four mothers consumed vitamin A-rich foods, and nearly one-third consumed iron-rich foods in the 24 hours preceding the survey. As the diet in Nepal is mostly plant based, it is likely that vitamin A rich foods listed in the survey were mainly of plant origin. Consumption of vitamin A-rich foods is higher among mothers residing in urban areas, mothers living in the hill zone, more educated mothers, and those in the highest wealth quintile. 2 Similarly, urban residence, education, and wealth are positively associated with consumption of iron-rich foods. Nevertheless, according to the most recently available data the percentage of night blindness among pregnant women (reported last pregnancy) is still high in the Terai, indicating that vitamin A deficiency remains a public health problem in this group. 17

18 Table 6 Prevalence of anemia among women of reproductive age (pregnant and non-pregnant combined) in Nepal (2011) Anemia status by severity a Any anemia Mild Moderate Severe Age y y y y y Residence Urban Rural Ecological zone Mountain Hill Terai Wealth quintile b Lowest Second Middle Fourth Highest b. Hemoglobin (g/dl) cut off points for: Any anemia <12.0 non-pregnant, <11.0 pregnant; mild non pregnant, pregnant; moderate ; severe <7.0. c. Prevalence by wealth quintile for the 2011 DHS has not yet been released; data reported are from DHS Table 7 Consumption of iron and vitamin A rich foods among women of childbearing age in Nepal (2006) Among women with child less than 3 years of age Percentage Percentage consumed consumed vitamin A iron richfoods rich-foods Percentage with night blindness during last pregnancy Among women with a child born in the past 5 years Percentage Number of days women took iron received tablets or syrup during pregnancy of vitamin A last birth dose postpartum Don t None < know 18 Percentage received iron tablets postpartum Age y y y y Residence Urban Rural Ecological zone Mountain Hill Terai Wealth quintile Lowest Second Middle Fourth Highest