Stunting, Women’s

Nutrition and South Asia

Dr. Sheila C Vir

Director and Senior Nutrition Specialist,
Public Health Nutrition and Development
Centre, New Delhi
 Women’s Nutrition

Major Contributor to Stunting

in South Asia
 Women's Nutrition and Stunting
Some Evidence Based Facts

•  Poor Women Nutrition (poor height, thinness, BMI, anaemia) impacts not only
maternal mortality but childhood stunting

•  Both direct nutritional and non-nutritional factors influence women’s nutrition

•  Poor women nutrition adversely impacts early child care: Contributes to

stunting

•  Poor women nutrition impairs foetal development - contributes to LBW and

increases the risk of stunting (2.1 to 4.3 times)
 Low Birth Weight in South Asia

 

•  52% of global burden



 
•  One in four children born are



with LBW

•  Burden is high in India,

 



Pakistan and Bangladesh




 



•  IUGR is the main contributor

of LBW in countries with
LBW >10 percent




 


 

 LBW, child stunting and women stature
Highest proportion of linear growth failure <12 months attributed to LBWs

40
35 Underweight
NDBC (%)
30
25 Stunted
Percent

NDBC (%)
20
15 Wasted
NDBC (%)
10
5 Stunted with
30% LBW
0
(%)
0.5 1 2 3 4 5
Age in years

New Delhi Birth Cohort. Sachdev 2011

 Stunting:
Women’s nutrition through life cycle
plays a critical role
Major pathways for women’s nutrition and stunting
Stunting and Poor Child
Care: 0-24 months

Largely irreversible
stunting by 24 months:
Poor start to adult
maternal stature
 Early childhood stunting 0-24 months
Predicts poor adult women stature

NFHS 3 (Cross-sectional 2005-2006)

60 NDBC (Longitudinal 1971-1976)

50
Percent of Children

40

30

20

10

0
0 6 12 24 36 48 60
Age in months

New Delhi Birth Cohort. Sachdev 2011)

Neglected adolescent and pre-conception
care: (poor maternal stature and anaemia):
Child Stunting
 Maternal Height
Association with Stunting Prevalence Rate




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1 cm increase in maternal height was associated with a significant decreased risk of child
mortality, underweight, stunting, wasting and anemia.

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 Low Maternal Height – a risk factor for stunting in children

Maternal Stature Study - 54 Countries (LIC/MIC)**:

  Shorter maternal stature  risk factor  mortality, underweight and stunting in

infancy and childhood

Effect size on childhood stunting:

  Almost twice that of being the lowest education category
  1.5 times that of being in the poorest quintile

  Gaining optimum height crucial for ”stop” stunting

**Analysis of 109 Demographic Health Surveys between 1991-2008

Source: Ozaltin et al, 2010
 Adolescent Height
Implications of Early Childhood Stunting

Mean Height Between 3-18 years for Rural (India)

Stunted and not stunted at 3 years
Rao et al 2012
Child stunting and height gain in adolescence

  Slower velocity and

elongated growth spurt
in stunted girls

  Height gain continues

for a few years after the
onset of menarche in
undernourished girls

Source: Rao S et al, 2012

 Percentage Girls Married and Birth by 18 Years
Higher risk of child stunting (1.2 to 1.5 times)

 




 































 









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Source: UNICEF, 2014
 Maternal Weight and Birth Weight:
Contributes to LBW and Child Stunting

 
 


   

 




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Source: Ramachandran, 1989

 Poor dietary intake in adolescence: Poor adult nutritional status
Women entering pregnancy thin/low BMI and poor micronutrient status

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Percentage with daily intake of nutrients <50% RDA

Percentage with daily consumption of food items < 50% RDI
NNMB, 2012
 Improvement in
Women Body Mass
Index (BMI) Reduces
LBW (1980s-2000s)

Source: Mason et al, 2012

 Poor Women’s Nutrition (BMI) and Child Stunting

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 Anaemia:
Adolescent girls/preconception stage
 Anaemia in Adolescent Girls:
A Serious
Norway 4
Public Health Problem In South Asia
USA 5.9

England 10.5

Thailand 17

Bhutan 26.4

Sri Lanka 40

Bangladesh 40

Myanmar 45.2

Nepal 46

Maldives 50

India 90

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
Percentage (% )
WHO Anaemia Prevention Guidelines for
Women in Reproductive Age (WRA):
Pregnancy too short a period for anaemia correction

WIFS Dosage:
•  WRA anaemia ≥ 20%
•  60mg elemental iron and 2.8mg
folic acid
•  Weekly IFA Supplements
(WIFS)
 Weekly IFA Supplements (WIFS) Policy for WRA:
Important Investment

•  WIFS and biannual deworming: Evidence annual anaemia reduction by one

third

•  “Fixed Day “ approach: Facilitates coverage and compliance

•  Social Marketing effective: Doable long term strategy (Cambodia,Vietnam,

Philippines)

•  WIFS Policy in SA countries: Only exists in India and Bangladesh - as of

2011

•  Comprehensive Anaemia and Folic Acid Deficiency Prevention Policy

critical.
 Pregnancy Care
and Stunting:

Suboptimum Coverage of
ANC, IFA supplement and
poor nutrient intake
 Dietary/ nutrient Intake: Pregnancy and non-pregnancy stage
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*States: Kerala, Tamilnadu, Karnataka, Andhra Pradesh, Maharashtra, Gujarat, Madhya Pradesh, Orissa, West Bengal, Uttar Pradesh

Source: NNMB, 2012

 Non-Nutrition Factors:
Influence Women’s Nutrition
and Stunting

Emerging Evidence

Age of conception
Education
Decision making Power
Domestic Violence
Highest Risk Factors Associated with Stunting in Young Children:
India, Nepal and Bangladesh









  
 


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Source: Adhikari, Vir et al, 2013; Heady & Hoddinott, 2013; Bhagowalia et al, 2012
Mother’s Education Level, Decision Making Power
influences Stunting in Children
 Women’s education level and child stunting in India

90
Mothers married by
80 76,5 age 18

Median age of 1st

70 64,8 birth (years)

60 57,2 Women with BMI

Percentage (%)

below normal
48
50 46,4 46,2
Women who have
40,9 42 40,7 ever experienced
40 34,9 spousal violence
32,4
28,7
30 27,4
23,6
18,7 19 20,1
16,3
20 14,1
16,2

10

0
No education <8 years 8-9 years 10 years and above
Source: NFHS-3, 2005-06
 Mother’s Education and child undernutrition (Pakistan)
30
26,6

25
Stunting
20 19,1
Prevalance (%)

17,1
Wasting
15,5
15
11,5 Underweight
9,8
10 8,1 8 8,5
6,4 6,5
5,8
4,9 5
5 4

0
Illiterate 1 - 5 years 6 - 8 years 9 - 10 years Above matric

Source: Pakistan National Nutrition Survey, 2012

 Women Status
Positive impact on Child Nutrition Strongest in South Asia

Source: Smith et al, 2003

 Women’s Decision Making Power:
Impact on Complementary Feeding: 3 Regions

Whether 6-12 months old Whether > 6 months old Number of times per day
receives complementary feeding receives high quality food > 6 months old eats

Smith et al, 2003, IFPRI

 Higher Maternal Education:
Decision Making: Accelerating Problem of Overweight in Women - Child Stunting?

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Source: UNICEF, 2014; NFHS-3 (2005-06)

 Domestic Violence: Malnutrition

•  Evidence limited: association alarming (India, Bangladesh)

•  Physical domestic violence/multiple incidents**

 Determinant of ill health
 Anaemia women (odds ratio=1.11 )
 Underweight women (odds ratio1.21)

•  Mechanisms not well understood

 Interferes with decision making/mobility/self-child caring
“Stop Stunting”
in South Asia:

Improving Women’s
Nutrition Imperative
 Women Nutrition: Renewed Commitment

•  UNICEF 1992: GOBI-FFF (Female Literacy, Fertility Control,

Food Supplementation)

•  WHA 2012: Global target 2025 - Prioritizes Stunting and

women's nutrition
 Target 1: 40% reduction in global number of stunted children <5yrs

 Target 2: 50% reduction in anaemia in reproductive age group.

 Target 3: 30% reduction in LBW

 Rapid Decline in Stunting in Selected Countries:
Adolescent and Women Care Special Strategy

State/country Maharashtra (India) 2006-2012 Nepal Bangladesh 1996/97 - 2011

2001-2011

Decrease in Stunting 39 % to 23.7 % 57% to 41 % 28 to 15%

Programme Focus Under twos, IYCF IYCF IYCF

Special Intervention •  ANC - Adequate weight •  Pregnant women-IFA •  Maternal care

promotion supplement

•  Family planning
•  Monitoring LBWs for “catch •  Family/age at first marriage
up”
•  Health Nutrition •  Secondary education of
•  Adolescent girls - Nutrition Education girls
education
 Stop Stunting: Interventions Across Life Cycle

•  Young Child Nutrition: First window of opportunity -

growth and prevent stunting

•  Adolescence: Second growth spurt - optimum height gain

•  Preconception(newly-weds): Entering pregnancy at right

age, well - nourished and informed

•  Pregnancy: Enable optimum foetal growth

 We Must Act Now
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