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CHILDHOOD MALNUTRITION in SRI LANKA: a ROAD MAP for the LAST MILE a Review of Literature Analysis of Correlates of Undernutrition a Qualitative Inquiry

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CHILDHOOD MALNUTRITION in SRI LANKA: a ROAD MAP for the LAST MILE a Review of Literature Analysis of Correlates of Undernutrition a Qualitative Inquiry CHILDHOOD MALNUTRITION IN SRI LANKA: A ROAD MAP FOR THE LAST MILE A review of literature Analysis of correlates of undernutrition A qualitative inquiry Childhood malnutrition in Sri Lanka: a road map for the last mile A review of literature Analysis of correlates of undernutrition A qualitative inquiry 2019 World Health Organization Childhood malnutrition in Sri Lanka: a road map for the last mile - A review of literature, Analysis of correlates of undernutrition, A qualitative inquiry, 2019 ISBN: 978-92-9022-784-7 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/ igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Childhood malnutrition in Sri Lanka: a road map for the last mile - A review of literature, Analysis of correlates of undernutrition, A qualitative inquiry: World Health Organization, Country Office for Sri Lanka; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.whoint/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Sri Lanka Suggested citation: World Health Organization (2019). Childhood malnutrition in Sri Lanka: a road map for the last mile: A review of literature, analysis of correlates of undernutrition, a qualitative inquiry. Contributors: Lalini C. Rajapaksa and Upul Senarath. Colombo: World Health Organization. Childhood malnutrition in Sri Lanka: ii a road map for the last mile List of Contributors Investigators Dr. Lalini C. Rajapaksa Prof. Upul Senarath Biostatisticians Prof. Upul Senarath Mr. Indika Siriwardena Project Assistants K. Partheepan J. Dushyantharaj K. Ravindran S. Sujendran V. Lokeesan P. Jayawardena J. K. Pushpakumara Childhood malnutrition in Sri Lanka: a road map for the last mile iii “We need to look at the world through the eyes of a mother, the head of a poor household, a small holder farmer, and a poor slum dweller to really understand the subtle and interlinked causes of hunger. In this way problems that seemed technical become people’s problems and as a result our response becomes more social, more human. I think this could be another mindset shift in our efforts to tackle hunger and undernutrition.” Mary Robinson, former President of Ireland and President of the Mary Robinson Foundation – Climate Justice Childhood malnutrition in Sri Lanka: iv a road map for the last mile Executive Summary This analysis aims to identify modifiable factors and points for intervention that would support the improvement of nutrition status in children under the age of five years. Multiple methods were used to achieve this objective: (i) Review of literature related to malnutrition in Sri Lanka; (ii) Secondary analysis of Sri Lanka Demographic and Health Survey 2016 data; (iii) District level comparisons and correlation analysis; and (iv) Qualitative study with key informant interviews (KII) and focus group discussions (FGD) of mothers in 6 districts. The review and analyses were guided by the UNICEF conceptual framework of malnutrition and a life cycle approach. According to Demographic and Health Survey (DHS) 2016, the prevalence of stunting in children aged less than 5 years has remained relatively unchanged from 2006-2016 at a rate of 17.3% with its severe form at 4%. Examination of the rates of stunting by age categories indicate that much of the insult occurs during the first 1000 days of life: ‘the critical window of opportunity for optimum growth’. Wasting (15.1%) and severe wasting (3.0%) appear to have marginally increased from 2006-016 though not statistically significant. The high prevalence of wasting is of very high public health significance. The prevalence of severe acute malnutrition (WHZ <-3) and moderate acute malnutrition (WHZ from <-2 to -3) in children under the age of 5 years were 3.0% and 12.1% respectively. The 2016 DHS reported that one in five children below the age of 5 years was underweight (20.5%), also of high public health significance. Although the child anthropometry indicators at national level were almost similar between the two survey periods, there were notable differences in the changes within sectors, provinces and districts. In both urban and rural sectors, the rates of stunting and severe stunting have not shown significant change between 2006 and 2016. However, the estate sector has shown a marked reduction in both stunting and severe stunting. Apart from protein energy malnutrition, micronutrient deficiencies were found in children under 5 years of age. The National Nutrition and Micronutrient Survey 2012 reported that nearly one third of the children aged 6-59 months were iron deficient The prevalence of anaemia in children aged 6-59 months was 15.1% with a wide inter-district variation. Zinc deficiency (5.1%) and calcium deficiency (47.6%) were also reported in these children. The DHS 2016 survey noted that 9.1% of ever married women were thin (BMI<18.5 kgm-2), and 45% were overweight or obese (BMI≥25.0 kgm-2). When compared with previous surveys, there is a decline in thinness and an increase in overweight and obesity. The mean height of Sri Lankan married women in the reproductive age according to the DHS 2016 was 152.7 cm (SD 6.1). The prevalence of women with heights below 145 cm for ever married women 15-49 years was 7%, compared to approximately 11% reported in the 2006 DHS. The National Nutrition Survey of Lactating Women (2015), identified a much lower figure of 4.4%. The lower prevalence was most likely due to a larger percentage of younger cohorts (43.4%) in this sample compared to the DHS 2016 (21%). Both surveys showed decreasing proportions of women below 145 cm in the younger age groups. suggesting a slow secular improvement in heights of Sri Lankan women. The National Nutrition and Micronutrient Survey of Pregnant Women (2015) reported that, the prevalence of thinness in pregnant women prior to 12 weeks of gestation was 22.5%. Weight gain during pregnancy appears to be inadequate among Sri Lankan women, the mean weight gain during pregnancy was 9.4kg (SD 5.0) as reported in the 2015 National Nutrition Survey of Lactating Women. More than 49% of mothers gained less than 10 kg of weight during pregnancy. Analysis of data collected during the nutrition month (2010) shows that even if the BMI at first visit is low, low birth weight rates can be reduced if the recommended weight gain is achieved during pregnancy. Optimum growth during the intra-uterine period is critical since a child’s future growth pattern is ‘set’ during foetal life. Low birthweight is an important determinant of undernutrition in childhood, and has intergenerational effects perpetuating a cycle of poor nutrition. In Sri Lanka, average birth weight has improved gradually over the years, but the pace of improvement has slowed down considerably in the last 10 years. The median birth weight stands at 2950 g for children born 5 years preceding the 2016 DHS. Breastfeeding and complementary feeding practices in infants and young children have improved between the two DHS, however there is a potential for further improvement, particularly to increase dietary diversity, intake of foods of animal origin and iron rich food and to reduce bottle feeding in young children.
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