Sakil Malik

Sakil Malik
maliksakil@hotmail.com

With a population of 125 million, Bangladesh is one of the most densely populated (800 persons per square kilometers) countries in the world. During the period 1960-94, the crude birth rate dropped from 47 to 36, as the death rate fell from 22 in 1960 to 13 in 1997 9age and sex standardized death rate per 100,000). The infant mortality rate (IMR) has also declined from 151 in 1960 and to 79 in 1998. The life expectancy has only marginally increased from 56.1 in 1991 to 58 in 1998. Maternal mortality ratio continues to be high with 390 per 100,000 births. The adult literacy rates are low in the country (combined = 38.1%, Male = 50.5%, Female = 35.9%). The human development index of Bangladesh is 0.461 (HDI Rank 146) and the per capita GNP is US$ 240. More than half of the country’s population live in poverty and the progress of alleviation programs in the country are the slowest in Asia.

What is malnutrition?

The term is used to refer to a number of diseases, each with a specific cause related to one or more nutrients (for example, protein, iodine or calcium) and each characterized by cellular imbalance between the supply of nutrients and energy on the one hand, and the body's demand for them to ensure growth, maintenance, and specific functions, on the other.

Nutritional Situation in Bangladesh

Protein Energy Malnutrition (PEM)
Currently, 56 percent of pre-school children are underweight, 51 percent stunted and 14.7 percent are wasted by international standards. Per capita dietary energy supply in Bangladesh shows a declining trend. Although Bangladesh has made a substantial progress in reducing the prevalence rate of stunting from 68 percent in 1985-86 to 51 percent in 1995-96 and underweight from 71 percent to 56 percent in 1995-96, moderate and severe malnutrition remains a major public health problem.

Anaemia

Data from the nutritional surveys indicate that Anaemia is a major public health concern within Bangladesh. The nutritional surveys carried out in rural Bangladesh in 1981-82 indicated that about 74 percent of pregnant and lactating women were anaemic. Among the under five children, 73 percent suffered from iron deficiency anaemia (IDA) and the country document on nutrition (1992) revealed that about 20 percent of maternal deaths were attributable to anaemia and post-partum hemorrhage. A small scale study undertaken during 1990-95 reported that IDA prevalence remained unchanged when compared to 1981-82 estimates. Inadequate intake and impaired absorption of iron, heavy parasitic infestation and recurrent infections are identified as the common causes. Bangladesh has no national program of prevention of nutritional anaemia and the problem has received low priority. Distribution of iron and folic acid supplements among pregnant women is sporadic and even that is channeled only through limited number of MCH-FP out reach government run centers.

Iodine Deficiency Disorders (IDD)

A national IDD prevalence survey carried out in 1993 revealed that total goiter prevalence rate was about 50 percent in children aged 5-11 years while prevalence of cretinism was 0.6 percent in the same age group. In the past 50 years, urinary iodine excretion has been taken as the gold standard employed for the assessment of iodine status and IDD. Data from 1993 indicate that the prevalence of low urinary excretion
(100µg/l) among school children (age 5-11) was 70.7 percent and among adults was 67.4 percent. Heavy rains, repeated flooding, continued trend of deforestation further aggravate the IDD problem. As a long-term measure, the universal iodination of common salt is being implemented in the country and legislation has been passed making iodination of all salt (produced and imported) mandatory. However, there is no effective monitoring of this program. As a result some businesses cheating people by selling regular salt as iodized salt.

Vitamin A Deficiency (VAD)

National baseline survey in 1996 reported that prevalence of night blindness dues to Vitamin A Deficiency (VAD) in pre-school children was 0.78 percent. Recent research (1999) from rural Bangladesh indicates that the prevalence of night blindness among rural pre-school children is 0.62 percent and among rural pregnant women is 2.7 percent. National VAD control program in Bangladesh is currently operated twice a year in pre-school children (6 months – 59 months) since 1995. More than 80 percent of children have received capsules during the special Vitamin A week campaign and distribution is linked with National Immunization Day (NID) with intensified Pulse Polio Immunization (PPI). In addition, other public health measures including dietary diversification are strongly advocated. Local NGOs such as BRAC, Proshika are taking a great role on this.

Feeding Status of Infants and Young Children

About 54 percent of children in rural Bangladesh are reported to be exclusively breast-fed till three months and 30 percent children are breast-fed along with complementary foods. In about 87 percent children, breast-feeding is continued for about two years along with other foods. Several prevailing superstitions interfere with appropriate breast-feeding. The use of breast milk substitutes is increasing in urban areas.

Diarrhoeal diseases and respiratory infections constitute the major killers and are also sources of morbidity and malnutrition among children in Bangladesh. Control of Diarrhoeal diseases by advocating exclusive breast-feeding up to 4-6 months, consumption of safe food, promoting ORS coverage among children needs a major thrust.

Malnutrition: A Global Perspective

Malnutrition kills, maims and disables

Malnutrition in its many forms persists in virtually all countries of the world in spite of a general improvement in food supplies and health conditions, and the increased availability of educational and social services.

An estimated 174 million under-five children in the developing world are malnourished as indicated by low weight for age, and 230 million are stunted. Malnutrition results in poor physical and cognitive development as well as lower resistance to illness. It is now recognized that 6.6 million out of 12.2 million deaths among children under-five - or 54% of young child mortality in developing countries - is associated with malnutrition. In addition to the human suffering, the loss in human potential translates into social and economic costs that no country can afford.

Over 800 million people still cannot meet basic needs for energy and protein, more than two thousand million people lack essential micronutrients, and hundreds of millions suffer from diseases caused by unsafe food or by unbalanced food intake.

In 1990, only 53 developing countries had reliable national data on the prevalence of underweight in young children; by 1995, 97 countries had such data, and 95 countries also had data on stunting and wasting.

It is estimated that more than half of the young children in south Asia suffer from protein- energy malnutrition, which is about five times the prevalence in the Western hemisphere, at least three times the prevalence in the Middle East and more than twice that of east Asia. Estimates for sub-Saharan Africa indicate that the prevalence is approximately 30%.

In some regions, such as sub-Saharan Africa and south Asia, stagnation of nutritional improvement combined with a rapid rise in population has resulted in an actual increase in the total number of malnourished children. Currently, over two-thirds of the world's malnourished children live in Asia (especially south Asia), followed by Africa and Latin America.

At the end of January 1996, 98 countries had national plans of action for nutrition and 41 countries had one under preparation, in keeping with their commitment made at the International Conference on Nutrition in Rome in December 1992.

While specific activities may vary, most programs that address childhood malnutrition include some conventional activities such as the protection and promotion of breast-feeding, appropriate complementary feeding, nutrition education for behavioral change, growth monitoring, micronutrient deficiency control, nutritional support of the sick child, maternal nutrition and health referral. What often distinguishes successful programs, is that communities are involved in identifying the problems and mobilizing action and resources for solving them; a good technical package is not sufficient.

More must be done to ensure good nutritional status of young women before they become mothers and to improve nutrition during pregnancy and lactation. Programs will require innovative approaches to reach adolescent girls, particularly in countries where their secondary school enrolment is low.

A focus on complementary feeding, combined with continued attention to protection, promotion and support of breast-feeding, will address an important cause of malnutrition. Programs must put special emphasis on the crucial period from birth to 18 months.

Overall malnutrition must no longer be considered without reference to micronutrient status as the two are inextricably linked. Attempting to improve protein-energy status without addressing micronutrient deficiencies will not result in optimal growth and function.

Many of the countries that have failed to achieve improvements in child malnutrition have been impeded because of emergency situations. More needs to be done to prevent nutritional emergencies and to design safety nets for the most vulnerable groups in case of emergency.

The International Center for Diarrhoeal Disease Research issued a report stating that over 80% of Bangladeshi Children suffer from malnutrition - and it continue to be a major cause of infant mortality. According to the World Bank Report, Wasting Away - the Crisis of Malnutrition in India, more than 50% of all children under four are malnourished with the most concentrated population in children under two years of age. Spending on "direct nutritional programs" accounts for 0.19% of India's GNP. 30% of Kenyan children under the age of five are "severely stunted." 45% of infants in Equador suffer from chronic malnutrition. In North Korea, 62% of children are underweight. Other areas of concern are Afghanistan, Angola and the Democratic People's Republic of the Congo.

Constraints and Actions for the Future

Bangladesh has not yet achieved self-sufficiency in food with 50 percent households experiencing food insecurity. Dietary energy supply accounts for only 80 percent of Recommended Daily Intake (RDI). The problem of malnutrition is further aggravated by in adequate supply of safe water, lack of sanitation, particularly in rural areas and urban slums accounting for high prevalence of Diarrhoeal diseases. These issues deserve high priority. Nutrition surveillance has not received due attention in national health and nutrition programs. Health workers are not able to realize the significance of cut-off level on growth charts resulting in inaction on their part when growth faltering occurs among children. Most of the well-planned health centers at district and lower levels run short of essential physical and logistic facilities and suffer from inadequate trained manpower. Issues regarding implementation of micronutrient malnutrition as well as Diarrhoeal diseases control programs are only partially addressed. Higher allocation of resources need to be made to improve the outreach of health care delivery.

In view of wide prevalence of malnutrition and poor outcome of the intervention programs, the government of Bangladesh has adopted programs to realize the national plan of action for nutrition in different ways. Primarily they are World bank funded projects: viz. Bangladesh Integrated Nutrition Project (BINP). Two other programs are underway: (1) nutritional activities are included in Health and Population Sector Program (HPSP) and, (2) National Nutrition Program (NNP) which is a nation-wide extension of BINP. However operational merits an demerits of these programs need to be carefully reviewed.

Bangladesh Integrated Nutrition Project (BINP)

In 1995, the government launched its first nationwide nutrition program with support from the World Bank through a US$59.8 million credit and from UNICEF. Under the Bangladesh Integrated Nutrition Project (BINP), the government works hand in hand with nongovernmental organizations and communities to tackle malnutrition, which affects about 90 percent of children, and to reduce high levels of anemia in pregnant and lactating women.

The community based nutrition program also includes family planning water and sanitation, and childcare. In the pilot areas, the core community-based nutrition activities have begun to have an impact on severe malnutrition among children ages 0 to 24 months; 92 percent of these children are covered by the growth-monitoring program, and 90 percent of the village committees participate in decision making. Furthermore, severe malnutrition among children in that age group in the project area has declined from above 20 percent to around 3 percent in just two years, 1995-97.

The project has been highly successful in enabling rural women to improve household decisions about nutrition and in getting them out of their homes to actively participate in activities likely to improve their own well-being.

National Nutrition Program (NNP)

The government of Bangladesh is contemplating launching a multi-million dollar new nutrition program similar to one now in progress and acclaimed as a model "path breaking" program by international experts. The existing Bangladesh Integrated Nutrition Project (BINP) will continue till December 2001. The new project, titled the "National Nutrition Program (NNP)", a four-year scheme-involving over Taka 6,00 crore or us 124 million dollars.

NNP is launched 18th months before the expiry of the existing Bangladesh Integrated Nutrition Project (BINP), a six-year program. The World Bank, Canadian International Development Agency (CIUA) and the Netherlands will finance the NNP while the UNICEF and the World Food Program (WFP) would provide technical assistance.

For further information, please contact Health Communications and Public Relations, WHO, Geneva. Telephone (41 22) 791 2543, Fax (41 22) 791 4858. All WHO Press Releases, Fact Sheets and Features can be obtained on Internet on the WHO home page http://www.who.ch/

External Affairs, The World Bank Bangladesh Office, 3A Paribagh Dhaka 1000 Bangladesh Tel : +(880)-(2)-861057-68, 9669301-8 Fax: +(880)-(2)-863220 Email: info@worldbank-bangladesh.org

World Health Organization, Regional Office for South-East Asia, World Health House, Indraprastha Estate
Mahatama Gandhi Marg, New Delhi 110 002, India, Telephone 91-11-331-7804 to 91-11-331-7823
FAX 91-11-3318607, 91-11-3327972, Email Documents Division: Alexeevv@whosea.org

UNICEF - Country Data - Bangladesh
http://www.unicef.org/programme/countryprog/rosa/bangladesh/stats.htm

The Columnist is:
Program Coordinator
International Office
Child Welfare League of America (CWLA), Inc.
440 First Street, NW, 3rd Floor,
Washington, DC 20001-2085
Phone: 202-942-0327
Fax: 202-638-4004
Email: msakil@cwla.org
www.cwla.org

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