1 Child undernutrition based on the new WHO growth standards and rates of reduction to 2015 Dr Mercedes de Onis SCN Annual Session, Hanoi, Viet Nam 2008
2 Intergenerational cycle of growth failure Child growth failure Intrauterine Growth Restriction Low weight & height in teenagers Undernourished mothers
3 Comparison of WHO with NCHS length/height-for-age z-scores for boys Length / Height (cm) 60 80 100 120 3 2 1 0-1 -2-3 WHO NCHS 0 2 4 6 8 12 16 20 24 28 32 36 40 44 48 52 56 60 Age (months) Source: WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization, 2006. Prevalence of stunting (below -2 SD length/height-for-age) by age based on the WHO standards and the NCHS reference in Bangladesh NCHS WHO % 80 70 60 50 40 30 20 10 0 0-5 6-11 12-23 24-35 36-47 48-60 0-60 Age (months) Source: de Onis M, Onyango AW, Borghi E, Garza C, Yang H, for the WHO Multicentre Growth Reference Study Group. Comparison of the WHO Child Growth Standards and the NCHS growth reference: implications for child health programs. Public Health Nutrition 2006;9:942-7.
4 Childhood stunting Global and regional estimates Region Stunting (below -2SD) (%) (millions) Africa 40 57 Asia 31 112 Latin America 16 9 All 32 178 Data source: WHO Global Database on Child Growth and Malnutrition Published in Lancet Series on Maternal and Child Undernutrition, Paper 1 178 Million Children Under 5 Suffer from Stunting Pre valen ce o f Stu ntin g < 20% 20-2 9.9% 30-3 9.9% =40 % No data Data source: WHO Global Database on Child Growth and Malnutrition Published in Lancet Series on Maternal and Child Undernutrition, Paper 1
5 The 20 countries with the highest burden of undernutrition Countries with stunting prevalence 20% in children under the age of 5 years that together account for >80% of the world's undernourished children Africa Democratic Republic of the Congo Ethiopia Kenya Madagascar Nigeria South Africa Sudan Uganda Tanzania Middle East Eg yp t Ye men Asia Afghanistan Bangladesh India Myanmar Nepal Pakistan Western Pacific Indonesia Philippines Vietnam Projections of prevalence of stunting compared with Millennium Development Goal Stunting 45 2015 MDG 40 %<-2SD 35 30 25 20 15 10 5 0 A frica Asia Latin America & the Caribbean Developing countries Developed countries Global Source: Data from WHO Global Database on Child Growth and Malnutrition; methods based on de Onis et al., JAMA 2004; 291: 2600-6, using WHO Child Growth Standards.
6 Projections of stunted children compared with Millennium Development Goal Millions 180 160 140 120 100 80 60 40 20 0 Stunting Af rica Asia Latin America & the Caribbean 2015 mio MDG Developing countries Developed countries Global Source: Data from WHO Global Database on Child Growth and Malnutrition; methods based on de Onis et al., JAMA 2004; 291: 2600-6, using WHO Child Growth Standards. Estimates of stunted children in 2005 and 2015 (millions) Region Stunting (below -2SD) 2005 2015 Africa 57 66 Asia 112 85 Latin America 9 7 All 178 157 Too high! Source: Data from WHO Global Database on Child Growth and Malnutrition; methods from de Onis et al, JAMA 2004;291:2600-6, using WHO Child Growth Standards.
Methodology for estimating trends in child malnutrition JAMA 2004;291:2600-2606. Limitations of projected estimates Availability of trend data is limited for a number of countries and some have not yet conducted national surveys it affects the precision of estimates for each region Surveys were not done randomly. Where and when surveys were conducted may biased estimates Variations in the data quality of the surveys Uncertainty in the UN population projections despite these limitations and the inherent speculative nature of extrapolations to 2015, the present estimates provide a useful base for monitoring progress towards the millennium goals 7
8 Severe wasting (below -3SD W/H) 19 million children are severely wasted New standards increase rates Odds ratio for overall mortality is 9.4 (5.3-16.8) Implement community and facility based management in parallel Severe wasting Usually caused by diets that do not provide sufficient nutrients and by high rates of infectious diseases
9 Girl's weight curve with malaria episodes (birth to 24 months) Weight (kg) 5 10 15 0 3 6 9 12 15 18 21 24 Source: Department of Nutrition, WHO Age (months) Impact of morbidity on weight gain during early childhood
10 Timing of growth faltering Height-for for-age by region Z-score (NCHS) 0.5 0.25 0-0.25-0.5-0.75-1 -1.25-1.5-1.75-2 -2.25-2.5 Africa Asia Latin America and Caribbean 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 Age (months) Source: Shrimpton, Victora, de Onis, et al. Pediatrics 2001;107(5). Mean length from birth to 24 months for the six MGRS sites Mean of Length (cm) 50 60 70 80 Brazil Ghana India Norw ay Oman USA 0 200 400 600 Age (days) WHO Multicentre Growth Reference Study Group. Assessment of linear growth differences among populations in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:56-65.
11 Damage suffered in early life leads to permanent impairment Undernourished children are more likely to become short adults and to give birth to low birth weight babies Evidence links stunting to cognitive development, school performance and educational achievement Poor fetal growth or stunting in the first 2 years of life leads to reduced economic productivity in adulthood Child's height for age is best predictor of human capital Source: Lancet Series on Maternal and Child Undernutrition, Paper 2 Measurements of two Maldivian children Age Height Weight BMI Girl X 2 yr 2 mo 86 cm 12 kg 16.2 Girl 4 yr 4 mo 86 cm 12 kg 16.2 Source: Department of Nutrition for Health and Development
32 30 Weight-for-height GIRLS 2 to 5 years (z-scores) 3 32 30 28 2 28 Weight (Kg) 26 24 22 20 18 16 1 0-1 -2-3 26 24 22 20 18 16 14 12 10 8 6 X 14 12 10 8 6 65 70 75 80 85 90 95 100 105 110 115 120 Height (cm) 125 Height-for-age GIRLS 2 to 5 years (z-scores) 3 125 120 2 120 115 1 115 110 0 110 Height (cm) 105 100 95-1 -2-3 105 100 95 90 85 X 90 85 80 80 75 Months 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 years 3 years 4 years 5 years Age (Completed months and years) 75 12
13 Measurements of two Maldivian children Age Height Weight BMI Girl X 2 yr 2 mo 86 cm 12 kg 16.2 Girl 4 yr 4 mo 86 cm 12 kg 16.2 Source: Department of Nutrition for Health and Development Issues in the measurement of height Equipment Training staff Interpretation of growth curve.but essential to identify stunted children (and obesity for countries with this concern)
14 Opportunity generated by new growth standards WHO standards have been generally well received providing an opportunity to redefine, refocus and reenergize all actions to promote child growth and development their introduction into countries can put a new focus on reducing malnutrition As part of implementation of new standards many countries are planning to incorporate the measurement of height to assess stunting at individual level (eg, Viet Nam, India, Bolivia) To date many countries are already using the standards (eg, Botswana, Bolivia, Brazil, Chile, Costa Rica, Guyana, Uruguay, Oman, Cyprus, Bhutan, Sri Lanka), have officially adopted them (eg, Argentina, India, Indonesia, Bangladesh, Cambodia, Malaysia, Zambia, Kenya, Viet Nam..75 countries) or are in the process of doing so (80 countries)
15 Investing in nutrition is worthwhile Child survival Physical growth Child development