Nutrition in Nepal: Three decades of commitment to children and women.

South Asia has made significant progress in reducing child undernutrition. The prevalence of stunting declined by one third between 2000 and 2019; as a result, in 2019, there were 34 million fewer stunted children than in 2000, indicating that progress for child nutrition is possible and is happening at scale. However, no country in South Asia is on track for all nutrition targets of Sustainable Development Goal 2, and the region has the highest prevalence of stunting (33.2%) and wasting (14.8%) in the world. Nepal, the best performing country in the region, narrowly missed the Millennium Development Goal (MDG) target to half the prevalence of child underweight between 1990 and 2015 and achieved the fastest recorded reduction in stunting prevalence in the world between 2001 and 2011. In 2019, UNICEF Nepal completed a series of papers to examine Nepal's progress on maternal and child nutrition during the MDG era. The series explores the trends, distribution and disparities in stunting, micronutrient deficiencies and feeding practices in children under 5 years and anaemia in adolescents and women. Besides, it reviews national micronutrient programmes (vitamin A supplementation, iron and folic acid supplementation and universal salt iodization) and Nepal's first Multi-Sector Nutrition Plan, to illuminate the success factors and enduring challenges in the policy and programme landscape for nutrition. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy and programme actions to improve maternal and child nutrition in Nepal and other similar contexts.

Triple trouble: Understanding the burden of child undernutrition, micronutrient deficiencies, and overweight in East Asia and the Pacific.

Young children in the East Asia and the Pacific region1 are failing to thrive, in large numbers, as indicated by stagnation in the decline of stunting, wasting, and micronutrient deficiencies and the fastest growing rates of overweight in the world. Eliminating the triple burden of malnutrition is essential to ensure that, as a matter of right, all children reach their full physical growth and development potential and actively contribute to equitable prosperity and the sustainable development of their communities and nations. Ending all forms of malnutrition will only be achieved through the implementation of effective policies and programmes soundly based on an understanding of the leading contextual drivers of child malnutrition. To address the lack of data on these drivers in the region, the UNICEF regional office for East Asia and the Pacific commissioned a series of papers in 2017-2019 to fill gaps in the current body of evidence on the triple burden of maternal and child malnutrition. This series includes analyses of the determinants of child malnutrition including maternal nutrition status, dietary quality of children, inequity, and poverty. Additionally, policy and programmatic actions associated with improved coverage and quality of nutrition interventions are reviewed. This overview paper summarizes the findings of these analyses and presents recommendations for the direction of future advocacy, policy, and programmatic actions to address the triple burden of malnutrition in East Asia and the Pacific.

Hidden hunger in South Asia: a review of recent trends and persistent challenges.

'Hidden hunger' is a term used to describe human deficiencies of key vitamins and minerals, also known as micronutrients. While global in scale, the prevalence of micronutrient deficiencies is particularly high in South Asia despite recent successes in economic growth, agricultural output and health care. The present paper reviews the most recent evidence on patterns and trends of hidden hunger across the region, with a focus on the most significant deficiencies - iodine, Fe, vitamin A and Zn - and interprets these in terms of health and economic consequences. The challenge for South Asian policy makers is to invest in actions that can cost-effectively resolve chronic nutrient gaps facing millions of households. Appropriate solutions are available today, so governments should build on evidence-based successes that combine targeted health system delivery of quality services with carefully designed multisector actions that help promote healthier diets, reduce poverty and ensure social protection simultaneously.

Education and micronutrient deficiencies: an ecological study exploring interactions between women's schooling and children's micronutrient status.

BACKGROUND: Formal education can be a nutrition-sensitive intervention that supports the scale-up and impact of nutrition-specific actions. Maternal education has long been linked to child survival, growth, and development while adult earnings and nutrition are tied to years in school as a child. However, less is known about the relationship between maternal education and the micronutrient status of children, women and the general population. METHODS: Using country-level data and an ecological study design, we explored the global associations between women's educational attainment and: a) anemia and vitamin A deficiency (VAD) in children aged 6-59 months; b) anemia in non-pregnant women; and c) zinc deficiency, urinary iodine excretion (UIE), and the proportion of infants protected against iodine deficiency in the general population Cross-sectional relationships (2005-2013) were assessed using linear regression models. RESULTS: Percentage of women without schooling was negatively associated with all outcomes. Number of years of schooling among women was positively associated with all outcomes except for UIE and the proportion of infants protected against iodine deficiency. Income level was a significant effect modifier of the effect of years of women's schooling on child anemia as well as of the proportion of women without formal education on zinc deficiency in the population. The relationship was strongest in low-income countries for child anemia, and was not significant in upper middle-income countries. For zinc deficiency, the relationship was not significant in low or lower middle income countries, which may suggest that a minimum threshold of resources needs to be reached before education can influence zinc status. CONCLUSIONS: While relationships between maternal schooling and micronutrient outcomes vary around the globe, more schooling is generally linked to lower rates of deficiency. These findings draw policy-relevant connections between formal education and anemia and micronutrient status globally. It is necessary to examine the mechanisms through which this relationship may be working at both household and country level.

Aiming higher for maternal and child nutrition in South Asia.

The sustainable development of nations relies on children developing to their full potential and leading healthy, productive, and prosperous lives. Poor nutrition in early life threatens the growth and development of children, especially so in South Asia, which has the highest burdens of stunting, wasting, and anaemia in the world. Targeted actions to reduce stunting and other forms of child malnutrition in South Asia should be informed by an understanding of what drives poor nutrition in children, who is most affected, and effective programme approaches. To this end, the UNICEF Regional Office for South Asia commissioned a series of papers in 2016-2017 to fill knowledge gaps in the current body of evidence on maternal and child nutrition in South Asia, including analyses of: (a) the links between anthropometric failure in children and child development; (b) the time trends, current distribution, disparities and inequities of child stunting, wasting and anaemia, and their direct and underlying causes, including maternal anaemia, low birth weight, breastfeeding, and complementary feeding; (c) policy and programme actions to increase the coverage of nutrition interventions during pregnancy, improve breastfeeding practices, and care for severely wasted children. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy, and programme actions to improve maternal and child nutrition in South Asia.

Determinants of anemia among women and children in Nepal and Pakistan: An analysis of recent national survey data.

Anemia remains one of the most intractable public health challenges in South Asia. This paper analyzes individual-level and household-level determinants of anemia among children and women in Nepal and Pakistan. Applying multivariate modified Poisson models to recent national survey data, we find that the prevalence of anemia was significantly higher among women from the poorest households in Pakistan (adjusted prevalence ratio [95% CI]: 1.10 [1.04-1.17]), women lacking sanitation facilities in Nepal (1.22 [1.12-1.33]), and among undernourished women (BMI < 18.5 kg/m2 ) in both countries (Nepal: 1.10 [1.00-1.21] and Pakistan: 1.07 [1.02-1.13]). Similarly, children in both countries were more likely to be anemic if stunted (Nepal: 1.19 [1.09-1.30] and Pakistan: 1.10 [1.07-1.14]) and having an anemic mother (Nepal: 1.31 [1.20-1.42] and Pakistan: 1.21 [1.17-1.26]). Policies and programs need to target vulnerable and hard-to-reach subpopulations who continue to bear a disproportionate burden of anemia. Covariates of poverty underpin rates of anemia among children and their mothers, but income growth alone will not suffice to resolve such deeply entrenched problems. Greater understanding of the relative role of various diet, health, sanitation, and educational factors by local context should guide investments to resolve anemia in tandem with stunting and maternal underweight.

Birthweight and feeding practices are associated with child growth outcomes in South Asia.

Although there has been a focus on preventing stunting over the past decade, wasting has received less policy and programmatic attention. Recent national surveys from six South Asian countries were pooled to generate a dataset of 62,509 children aged 0 to 59 months to explore associations between low birthweight (LBW) and suboptimal infant and young child feeding (IYCF) practices with child wasting, severe wasting, and the co-occurrence of wasting and stunting. Logistic regression models accounted for the surveys' clustered designs and adjusted for a potential confounding factors. Children with reported LBW had significantly higher odds of being wasted (adjusted odds ratio [95% CI]: 1.60 [1.45, 1.76]) or severely wasted (1.57 [1.34, 1.83]), compared with non-LBW children. Similarly, children aged 0 to 23 months who were not breastfed within the first hour post-partum, those who were provided prelacteal feeds, and those aged 0 to 5 months who were not exclusively breastfed, were more likely to be wasted (P < 0.05 for all three feeding practices). In India, not achieving minimum diet diversity and minimum adequate diet were significantly associated with the co-occurrence of stunting and wasting. In other words, many key domains of concern to development agents who seek to address stunting are also of direct concern to those focused on wasting. The co-occurrence of wasting and stunting requires more integrated interventions. That is, programmes aimed at preventing LBW and poor IYCF to avert stunting should be linked more effectively with actions aimed at the management of wasting.

Association between stunting and early childhood development among children aged 36-59 months in South Asia.

Stunting (length-for-age z score < -2) before 2 years of age has shown associations with poor child developmental indicators, but information at the population level is scarce in South Asia, the region with the highest burden of stunting. We examined associations between z scores (i.e., height for age [HAZ], weight for age [WAZ], and weight for height [WHZ]) and undernutrition (i.e., stunting [HAZ < -2], wasting [WHZ < -2], and underweight [WAZ < -2]) with learning/cognition and social-emotional development among children 36-59 months of age. Data from Multiple Indicator Cluster Surveys in Bangladesh (n = 8,659), Bhutan (n = 2,038), Nepal (n = 2,253), and Pakistan (Punjab n = 11,369 and Sindh n = 6,718) were used. Children were considered developmentally "on-track" in learning/cognition or social-emotional domains if they met specific early child development criteria. Meta-analysis was conducted to examine regional associations, adjusting for socio-economic status, early childhood education, and quality of care. In a pooled sample, on-track learning/cognition development was positively associated with HAZ (OR = 1.17, 95% CI [1.07, 1.27]) and WAZ (OR = 1.18, 95% CI [1.07, 1.31]) and negatively associated with stunting (OR = 0.72, 95% CI [0.60, 0.86]) and underweight (OR = 0.75, 95% CI [0.66, 0.86]) but not associated with WHZ or wasting. On-track development of social-emotional domain was not associated with any z scores or undernutrition indicators. Across several countries of South Asia, stunted children were less likely to be developmentally "on track" for learning/cognition. It is likely that interventions that prevent stunting may benefit child development, leading to significant individual and societal gains given the large burden of child stunting in regions like South Asia.

Predictors of complementary feeding practices in Afghanistan: Analysis of the 2015 Demographic and Health Survey.

Despite improvements over the past 20 years, high burdens of child mortality and undernutrition still coexist in Afghanistan. Global evidence indicates that complementary feeding (CF) practices predict child survival and nutritional status. Our study aims to describe CF practices in Afghanistan and to discern underlying predictors of CF by analysing data from Afghanistan's 2015 Demographic and Healthy Survey. Multilevel models were constructed comprising potential predictors at individual, household, and community levels and four CF indicators: timely introduction of solid, semi-solid, or soft foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD) among breastfed children. INTRO prevalence among children aged 6-8 months was 56%, whereas the prevalence of MMF, MDD, and MAD among children aged 6-23 months was 55%, 23%, and 18%, respectively. Of the seven food groups considered, four were consumed by 20% or fewer children: eggs (20%), legumes and nuts (18%), fruits and vegetables (15%), and flesh foods (14%). Increasing child age and more antenatal care visits were significantly and positively associated with greater odds of meeting all CF indicators. Lower household wealth and lower community-level access to health care services were associated with lower odds of MDD and MAD. Disparities in achieving recommended CF practices were observed by region. CF practices in Afghanistan are poor and significant socioeconomic inequities in CF are observed across the country. Our study calls for urgent policy and programme attention to improve complementary feeding practices as an intrinsic part of the national development agenda.

Stagnating trends in complementary feeding practices in Bangladesh: An analysis of national surveys from 2004-2014.

Bangladesh has experienced steady socio-economic development. However, improvements in child growth have not kept pace. It is important to document complementary feeding (CF) practices-a key determinant of children's growth-and their trends over time. The study aims to examine trends in CF practices in children aged 6-23 months using data from Bangladesh Demographic and Health Surveys conducted in 2004, 2007, 2011, and 2014. Multilevel logistic regression models were applied to identify independent predictors of four CF practice indicators among children 6-23 months, namely, timely introduction of complementary foods, minimum meal frequency, minimum dietary diversity, and minimum acceptable diet. Introduction of complementary foods was achieved among 64-71% of children between 2004 and 2014. The proportion meeting minimum meal frequency increased from 2004 to 2007 (71-81%) and declined and held steady at 65% from 2011 to 2014. The proportion meeting minimum dietary diversity in 2011 and 2014 was low (25% and 28%), and so was minimum acceptable diet (19% and 20%). From 2007 to 2014, child dietary diversity decreased and the most decline was in the consumption of legumes and nuts (29% to 8%), vitamin A-rich fruits and vegetables (54% to 41%), and other fruits and vegetables (47% to 20%). Young child age (6-11 months), poor parental education, household poverty, and residence in the Chittagong and Sylhet independently predicted poorer feeding practices. Dietary diversity and overall diet in Bangladeshi children are strikingly poor. Stagnation or worsening of feeding practices in the past decade are concerning and call for decisive policy and programme action to address inappropriate child feeding practices.

Trends in inequalities in child stunting in South Asia.

We analysed socio-economic inequalities in stunting in South Asia and investigated disparities associated with factors at the individual, caregiver, and household levels (poor dietary diversity, low maternal education, and household poverty). We used time-series analysis of data from 55,459 children ages 6-23 months from Demographic and Health Surveys in Bangladesh, India, Nepal, and Pakistan (1991-2014). Logistic regression models, adjusted for age, sex, birth order, and place of residency, examined associations between stunting and multiple types of socio-economic disadvantage. All countries had high stunting rates. Bangladesh and Nepal recorded the largest reductions-2.9 and 4.1 percentage points per year, respectively-compared to 1.3 and 0.6 percentage points in India and Pakistan, respectively. Socio-economic adversity was associated with increased risk of stunting, regardless of disadvantage type. Poor children with inadequate diets and with poorly educated mothers experienced greater risk of stunting. Although stunting rates declined in the most deprived groups, socio-economic differences were largely preserved over time and in some cases worsened, namely, between wealth quintiles. The disproportionate burden of stunting experienced by the most disadvantaged children and the worsening inequalities between socio-economic groups are of concern in countries with substantial stunting burdens. Closing the gap between best and worst performing countries, and between most and least disadvantaged groups within countries, would yield substantial improvements in stunting rates in South Asia. To do so, greater attention needs to be paid to addressing the social, economic, and political drivers of stunting with targeted efforts towards the populations experiencing the greatest disadvantage and child growth faltering.

Community management of acute malnutrition (CMAM) programme in Pakistan effectively treats children with uncomplicated severe wasting.

Severe wasting is the most widespread form of severe acute malnutrition, affecting an estimated 17 million children globally. This analysis assesses the effectiveness of Pakistan's community management of acute malnutrition (CMAM) programme. We conducted a retrospective case series analysis of 32,458 children aged 6-59 months who were admitted to the programme with a mid-upper arm circumference (MUAC) < 115 mm (January 1-December 31, 2014). We found that at admission, 59.6% of the children were girls and 87.4% were in the age group 6-23 months old. While in the programme, 120 children (0.4%) died, 3,456 (10.6%) defaulted, and 28,882 (89.0%) were discharged after a mean length of stay of 69.3 ± 25.7 days. Children's mean weight gain while in the programme was 3.2 ± 2.7 g/kg body weight/day. At discharge, 28,499 children (98.7% of discharged) had recovered (MUAC ≥ 125 mm). The odds of death were significantly higher among children with weight-for-height (WHZ) < -3 and/or height-for-age (HAZ) < -2 at admission. The odds of recovery on the basis of MUAC ≥125 mm were higher among children with HAZ ≥ -2 at admission. The odds of recovery on the basis of WHZ ≥ -2 were significantly higher among children with WHZ ≥ -3 and/or HAZ < -2 at admission. Pakistan's CMAM programme is effective in achieving good survival and recovery rates. Population-level impact could be increased by giving priority to children 6-23 months old and children with multiple anthropometric failure and by scaling up CMAM in the provinces and areas where the risk, prevalence, and/or burden of severe acute malnutrition is highest.

Trends and predictors of appropriate complementary feeding practices in Nepal: An analysis of national household survey data collected between 2001 and 2014.

There is evidence that suboptimal complementary feeding contributes to poor child growth. However, little is known about time trends and determinants of complementary feeding in Nepal, where the prevalence of child undernutrition remains unacceptably high. The objective of the study was to examine the trends and predictors of suboptimal complementary feeding in Nepali children aged 6-23 months using nationally representative data collected from 2001 to 2014. Data from the 2001, 2006, and 2011 Nepal Demographic and Health Surveys and the 2014 Multiple Indicator Cluster Survey were used to estimate the prevalence, trends and predictors of four WHO-UNICEF complementary feeding indicators: timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). We used multilevel logistic regression models to identify independent factors associated with these indicators at the individual, household and community levels. In 2014, the weighted proportion of children meeting INTRO, MMF, MDD, and MAD criteria were 72%, 82%, 36% and 35%, respectively, with modest average annual rate of increase ranging from 1% to 2%. Increasing child age, maternal education, antenatal visits, and community-level access to health care services independently predicted increasing odds of achieving MMF, MDD, and MAD. Practices also varied by ecological zone and sociocultural group. Complementary feeding practices in Nepal have improved slowly in the past 15 years. Inequities in the risk of inappropriate complementary feeding are evident, calling for programme design and implementation to address poor feeding and malnutrition among the most vulnerable Nepali children.

Epidemiology of anaemia in children, adolescent girls, and women in Bhutan.

Anaemia inhibits health and development in Bhutan. We estimated anaemia prevalence and explored risk factors in children and women using data from Bhutan's National Nutrition Survey 2015. Prevalence was calculated using life-stage-specific cut-offs adjusted for altitude and survey design. Risk factors were evaluated in modified Poisson regressions. Anaemia affected 42%, 29%, 36%, and 28% of children, adolescent girls, and non-pregnant and pregnant women, respectively. Risk of anaemia was greater in children who were younger (RR 2.0, 95% CI [1.7, 2.3] and RR 1.9, 95% CI [1.6, 2.3], respectively, for 12-23 and 6-11 vs. 24-59 months), male (1.2, 1.1-1.4, ref.: female), and stunted (1.2, 1.0-1.3, ref.: height-for-age ≥ -2z). Older (15-19 years) versus younger (10-14 years) adolescents were at higher risk (1.5, 1.2-1.8), as were adolescents living at home versus at school (1.2, 0.9-1.6) and those working versus studying (1.3, 1.0-1.7). Among adult women, anaemia risk increased with age (1.2, 1.0-1.4 and 1.3, 1.1-1.5, for 30-39 and 40-49, respectively, vs. 20-29 years) and was higher for women without schooling (1.1, 1.0-1.3, vs. primary schooling), who were unmarried or separated (1.4, 1.2-1.7 and 1.3, 1.1-1.6, respectively, vs. married), without a child <5 years (1.1, 1.0-1.3), and lacking improved sanitation (1.1, 1.0-1.3). High coverage of antennal iron and folic acid supplementation may contribute to the lower prevalence of anaemia among pregnant women and women with young children. Expansion of iron supplementation programmes, fortification, and other strategies to improve dietary iron intake may reduce the prevalence of anaemia, but causes of anaemia other than iron deficiency (e.g., thalassemias) should also be investigated.

Infant and young child feeding practices and nutritional status in Bhutan.

In South Asia, childhood undernutrition persists while overweight is increasing. Internationally recommended infant and young child feeding (IYCF) practices promote healthy nutritional status; however, little is known about IYCF in Bhutan, investigated here using 2015 National Nutrition Survey data. WHO/UNICEF IYCF indicators, anthropometry and household socio-economic status were available for 441 children <24 months. Stunting, wasting, and underweight prevalence (<-2Z length-for-age [LAZ], weight-for-age, [WAZ] and weight-for-length [WLZ], respectively) were 15%, 9%, and 5%, respectively, whereas overweight (WLZ >2) prevalence was 6%. In survey-design-adjusted analyses, 52% of mothers of 0- to 5-month olds reported exclusive breastfeeding (EBF), with EBF less common for girls than boys (OR: 0.2 [95% CI: 0.1-0.9]). Although 61% of children were breastfed at 2 years and 75% of children >6 months met a minimum daily meal frequency, only 18% of children 6-23 months met minimum dietary diversity. IYCF was unassociated with risk of stunting, wasting, or underweight, possibly due to relatively low prevalence of anthropometric failure and small sample size. However, currently-breastfed children were less often overweight [OR: ~0.1 (95% upper limit ≤1.0)]. Neither breastfeeding nor most complementary feeding practices differed by socio-economic status, but children in the highest two fifth of a wealth index had 7.8 (1.3-46.9) and 5.3 (1.1-25.2) times greater odds than children in the lowest fifth of meeting minimum dietary diversity criteria. Low rates of EBF, given possible protection of breastfeeding against overweight, and inadequate dietary diversity offer evidence to guide future program interventions to improve nutritional status of young children.

Nutritional status and risk factors for stunting in preschool children in Bhutan.

Childhood malnutrition remains endemic in South Asia, although the burden varies by country. We examined the anthropometric status and risk factors for malnutrition among children aged 0-59 months through the 2015 National Nutrition Survey in Bhutan. We assessed in 1,506 children nutritional status (by z-scores of height-for-age [HAZ], weight-for-height [WHZ], and weight-for-age [WAZ]), estimating prevalence, adjusted for survey design, of stunting, wasting, underweight, and overweight (<-2 for HAZ, WHZ, and WAZ and >2 for WHZ). Children were also assessed for pedal oedema. We conducted multivariable linear/logistic regression analysis to identify child, maternal, and household risk factors for childhood undernutrition and overweight, excluding children with oedema (1.7%). Mean (SE) HAZ, WHZ, and WAZ were -0.82 (0.13), 0.10 (0.04), and -0.42 (0.05), respectively. Prevalence of stunting, wasting, underweight, and overweight were 21.2%, 2.6%, 7.4%, and 2.6%, respectively. In multivariable regressions, risk of stunting significantly increased by age: 5.3% at <6 months (reference), 16.8% at 6-23 months (OR = 3.06, 95% CI [0.63, 14.8]), and 25.0% at 24-59 months (OR = 5.07, [1.16, 22.2]). Risk of stunting also decreased in a dose-response manner with improved maternal education. None of the examined variables were significantly associated with wasting or overweight. Despite a WHZ distribution comparable with the World Health Organization reference (with ~2.6% vs. an expected 2.5% of children beyond 2 z in each tail), stunting persists in one fifth of preschool Bhutanese children, suggesting that other nutrient deficits or nonnutritional factors may be constraining linear growth for a substantial proportion of children.

Infant and young child feeding practices and nutritional status in Bhutan.

In South Asia, childhood undernutrition persists while overweight is increasing. Internationally recommended infant and young child feeding (IYCF) practices promote healthy nutritional status; however, little is known about IYCF in Bhutan, investigated here using 2015 National Nutrition Survey data. WHO/UNICEF IYCF indicators, anthropometry and household socio-economic status were available for 441 children <24 months. Stunting, wasting, and underweight prevalence (<-2Z length-for-age [LAZ], weight-for-age, [WAZ] and weight-for-length [WLZ], respectively) were 15%, 9%, and 5%, respectively, whereas overweight (WLZ >2) prevalence was 6%. In survey-design-adjusted analyses, 52% of mothers of 0- to 5-month olds reported exclusive breastfeeding (EBF), with EBF less common for girls than boys (OR: 0.2 [95% CI: 0.1-0.9]). Although 61% of children were breastfed at 2 years and 75% of children >6 months met a minimum daily meal frequency, only 18% of children 6-23 months met minimum dietary diversity. IYCF was unassociated with risk of stunting, wasting, or underweight, possibly due to relatively low prevalence of anthropometric failure and small sample size. However, currently-breastfed children were less often overweight [OR: ~0.1 (95% upper limit ≤1.0)]. Neither breastfeeding nor most complementary feeding practices differed by socio-economic status, but children in the highest two fifth of a wealth index had 7.8 (1.3-46.9) and 5.3 (1.1-25.2) times greater odds than children in the lowest fifth of meeting minimum dietary diversity criteria. Low rates of EBF, given possible protection of breastfeeding against overweight, and inadequate dietary diversity offer evidence to guide future program interventions to improve nutritional status of young children.

Determinants of child wasting in Bhutan. Insights from nationally representative data.

OBJECTIVE: To characterize the epidemiology of wasting and identify the main predictors of wasting, severe wasting and poor weight-for-height in children. DESIGN: We analysed a nationally representative sample of 2028 children (Multiple Indicator Survey, 2010). SETTING: Royal Kingdom of Bhutan. SUBJECTS: Children aged 0-23 months. RESULTS: Wasting prevalence was significantly higher among infants aged 0-11 months than among children aged 12-23 months (12·0 v. 6·7 %; P=0·004) and among boys than girls (11·0 v. 7·5 %; P=0·04). Children from the Western region had 63 % higher odds of being wasted than children from the Central/Eastern regions (adjusted OR (AOR)=1·63; 95 % CI 1·14, 2·34). Poor feeding practices were among the most significant predictors of wasting and severe wasting. Children who were given prelacteal feeds in the first days of life had 2·5 times higher odds of being severely wasted than those who were not (AOR=2·49; 95 % CI 1·19, 5·19); inadequate complementary feeding in children aged 0-23 months was associated with 58 % higher odds of being wasted (AOR=1·58; 95 % CI 1·02, 2·47) and 2·3 times higher odds of being severely wasted (AOR=2·28; 95 % CI 1·13, 4·58). The association of poor infant feeding practices with wasting and severe wasting was particularly significant in infants (0-11 months). CONCLUSIONS: Programmes for the detection and treatment of severely wasted children need to prioritize very young children (0-11 months), particularly in the Western region. Programmes for the prevention of wasting need to prioritize the improvement of complementary foods and feeding practices in children aged 6-23 months.

Complementary feeding practices for infants and young children in South Asia. A review of evidence for action post-2015.

Some 37% (~64 million) South Asian children under 5 years are stunted. Most stunting occurs during the complementary feeding period (6-23 months). Our objective was to (a) characterize complementary feeding practices in South Asia and (b) review the effectiveness of information, education, and counselling (IEC) interventions aiming to improve complementary feeding in South Asia. We conducted a comprehensive review of (a) the latest nationally representative survey data and (b) peer-reviewed interventions (January 1990 to December 2015) that used IEC as the main strategy to improve complementary feeding. The analytical sample included 30,966 children aged 6-23 months. Foods made from grains are the main complementary food (76.8% of children). Only 33.2% of children are fed fruits and vegetables rich in vitamin A and a mere 17.1% are fed complementary foods containing meat, fish, poultry and/or eggs. Timely introduction, minimum meal frequency, minimum dietary diversity, and minimum acceptable diet were estimated at 57.4%, 47.7%, 33.0%, and 20.5%, respectively. The evidence on the effectiveness of IEC interventions is limited in quantity, quality, and scale. The 12 intervention studies that met the inclusion criteria indicate that IEC interventions delivered by many types of primary care workers/community resource persons using multiple contact opportunities improved the timeliness, frequency, diversity, and/or adequacy of complementary feeding. However, acceptability, availability, and affordability seem to constrain improvements in diet diversity, particularly foods of animal origin. The small size of most intervention studies and the training and/or supervision intensity of counsellors raise concerns about the potential for scale and/or sustainability of some of the interventions reviewed.

First foods: Why improving young children's diets matter.

Globally, only 52% of children aged 6-23 months meet the minimum meal frequency and a mere 29% meet the minimum dietary diversity, with large disparities across and within regions. With most of the stunting occurring during the first thousand days-from conception to age 2 years-improving complementary feeding in children 6-23 months old is an urgent priority. With this evidence in mind, UNICEF collaborated with the governments of India and Maharashtra to convene a global meeting in Mumbai, India, under the theme: First Foods: A Global Meeting to Accelerate Progress on Complementary Feeding in Young Children (November 17-18, 2015). The global meeting provided a platform that aimed to (a) synthesize the biological and implementation science on complementary feeding; (b) review the practice and experience in improving access to nutritious complementary foods and good complementary feeding practices; and (c) consolidate a strong evidence base that can inform the development of strategies and approaches to improve complementary feeding that are fit to context. This overview paper summarizes the rationale on why improving complementary foods and feeding for infants and young children matters and what it takes to improve them. It builds on the papers presented at the First Foods Global Meeting and those commissioned as a follow on to it.