What is energy balance?
It is important to take into account the variability linked to sampling. However, if a specific programme has been successfully carried out among these families, this indicator could lose its validity. In addition, re-orientation training of the staff is carried out every year. Dietary aides in some countries might also carry out a simple initial health screening for newly admitted patients in medical facilities, and inform the dietitian if any screened patients requires a dietitian's expertise for further assessments or interventions. Recall techniques, on the contrary, can easily be applied to a large sample, obviously with a smaller confidence interval. There must, in particular, be a consensus on the level and significance of cut-off points for classification.
Canadian Definition of Homelessness
The study design and Sampling procedure Survey methodology, development, pre-testing and finalization of survey instruments are worked out at Central Reference Laboratory CRL , National Institute of Nutrition, Hyderabad.
In addition, re-orientation training of the staff is carried out every year. The data collected, using standardized pre-tested questionnaires, includes: Nutrition monitoring is the measurement of the changes in the nutritional status of a population or a specific group of individuals over time WHO, The paucity of reliable and comparable data from all parts of the country is a definite obstacle towards a realistic and disaggregated problem definition.
This calls for a nation-wide monitoring system. To achieve this, it is necessary to restructure and strengthen the existing National Nutrition Monitoring Bureau NNMB and to develop a mechanism for generating nationwide disaggregated data. National Nutrition Policy, Govt. Eastern Europe and Central Asia had the highest overweight prevalence in with The lowest overweight prevalence in was seen in South Asia, at 3.
East Asia and the Pacific had the highest number of overweight children in with 8. Overall the two Asian regions East Asia and the Pacific and South Asia account for more than one out of every three overweight children in the world. Eastern Europe and Central Asia as well as North America are the only regions that have seen a statistically significant increase in number of overweight children between and In globally, 51 million children under five were wasted of which 16 million were severely wasted.
This translates into a prevalence of 7. In , more than half of all wasted children lived in South Asia and about one quarter in sub-Saharan Africa, with similar proportions for severely wasted children.
Under-five wasting and severe wasting are highly sensitive to change. Thus, estimates for these indicators are only reported for current levels In almost all countries with available data, stunting rates are higher among boys than girls. While analyses to determine underlying causes for this phenomenon are underway, an initial review of the literature suggests that the higher risk for preterm birth among boys which is inextricably linked with lower birth weight is a potential reason for this sex-based disparity in stunting.
Analysis is based on a subset of 92 countries with recent data by wealth quintile groupings covering 69 per cent of the global population. Children from the poorest 20 per cent of the population have stunting rates that are double the rate in comparison with the richest quintile. In South Asia, the absolute disparities between the richest and poorest children in regard to stunting are greater than in any other region.
While the overall rates are lower, the relative disparities are greatest in Latin America and the Caribbean where the rate among the poorest is more than 4 times higher than among the richest. An analysis of 54 countries with comparable trend data between around and around shows that gaps between the poorest 20 per cent and richest 20 per cent of children under five have closed by at least 20 per cent in the majority of upper-middle-income countries.
However, in almost all low income countries, this gap has either remained the same or increased. Blencowe H et al. Preterm birth—associated neurodevelopmental impairment estimates at regional and global levels for Pediatric Research Volume No s1, December Please note that some children can suffer from more than one form of malnutrition — such as stunting and overweight or stunting and wasting.
There are currently no joint global or regional estimates for these combined conditions, but UNICEF has a country-level dataset with country level estimates, where re-analysis was possible.
Prevalence of stunting, wasting and overweight among children under 5 is estimated by comparing actual measurements to an international standard reference population. The new standards are the result of an intensive study project involving more than 8, children from Brazil, Ghana, India, Norway, Oman and the United States.
Overcoming the technical and biological drawbacks of the old reference population, the new standards confirm that children born anywhere in the world and given the optimum start in life have the potential to reach the same range of height and weight. The new standards should be used in future assessments of child nutritional status. It should be noted that because of the differences between the old reference population and the new standards, prevalence estimates of child anthropometry indicators based on these two references are not readily comparable.
It is essential that all estimates are based on the same reference population preferably the new standards when conducting trend analyses. Before conducting trend analyses of child nutritional status, it is important to ensure that estimates from various data sources are comparable over time. For example, household surveys in some countries in the early s only collected child anthropometry information among children up to 47 months of age — or even up to only 35 months of age.
Prevalence estimates based on such data only referred to children under 4 or under 3 years of age and are not comparable to prevalence estimates based on data collected from children up to 59 months of age.
Some age adjustment needs to be applied to make these estimates based on non-standard age groups comparable to those based on the standard age range.
For more information about age adjustment, please click here to read a technical note. In addition, prevalence estimates need to be calculated according to the same reference population. For more information about the difference between the two references and its implications, please click here to read a series of questions and answers.
When data collection begins in one calendar year and continues into the next, the survey year assigned is the one in which most of the fieldwork took place.
A high prevalence of low hemoglobin levels, in addition to a low amount of bioavailable iron in diets, may constitute the basic indicators of iron deficiency anemia in a population, provided there is a consensus on their meaning and on the cut-off values used. If a strategy of fortifying a vector food with iron is adopted, in view of the extent and homogeneity of the phenomenon in the population, regardless of age or sex, repeatedly measuring the same indicators and comparing them to previous values or to an international reference, will allow evaluating the effectiveness of the strategy.
Nevertheless, it will probably also be necessary to include a whole series of indicators of health status, of the use of the health care system, of dietary patterns and food availability, or perhaps of manufacturing and distribution channels, in order to provide an overall picture of the problem, its causes and possible solutions and to allow evaluation of actions undertaken.
Choosing and prioritizing actions to combat undernutrition will depend primarily on the information regarding the nutritional status of the population. Such information will be provided by indicators of status, allowing to characterize the nature of the undernutrition problem.
They will then be linked to the characteristics of persons, times and places, in order to obtain an indication of the distribution of the problem in the population, and thus reach an overall picture of the situation. Who suffers from undernutrition?
What is the type of undernutrition? Where are these malnourished individuals? Precisely defining the nutritional status of a person, and more so of a population, is difficult. It is a global concept which can only be grasped through a set of clinical, physical or functional characteristics which could constitute as many potential indicators if a cut-off value were attributed to them allowing to separate malnourished individuals from well-nourished ones.
This task has been carried out - and there has been a consensus on it - mainly in the fields of child and adult malnutrition and of deficiency in three micronutrients which are widespread and have serious consequences in terms of public health vitamin A, iodine and iron.
First of all, measurements or corresponding indices are collected at individual level for example, weight, arm circumference, hemoglobin level, etc. This information is then expressed at the level of the population group concerned, in the form of prevalence rates, in other words, percentages of individuals who are well- or malnourished with respect to the form of malnutrition considered, in accordance with cut-off values chosen.
The use and interpretation of these indicators of status are presently well-established. Nevertheless, it is useful to consult a specialist for selecting and interpreting them, as these indicators can reflect, for example, either a likely risk simple deviation from a norm or a real risk of nutrient deficiency recognised functional deficit , either a recent or old, acute or chronic history of undernutrition wasting, stunting in the young child.
Some indicators are useful at population level rather than at individual level. Finally, some will be more useful than others for anticipating the benefit of a possible intervention. Once the nutritional status of the population and its geographical or socio-economic distribution are known, and goals for improvement have been set, information is needed on the determinants of the situation; in other words, on the factors, events or characteristics which are likely to affect the nutritional status of individuals within the population at different levels.
It will then be possible to define a strategy seeking to alter a number of these factors to improve the situation as reflected in the stated objectives. This sector includes a wide range of potential indicators covering agricultural production, food marketing and food consumption.
A number of them are regularly collected by the information systems operated by Ministries of Agriculture and Trade. Environmental hygiene aspects encompass water supply, and supply of healthy food products, sanitation in a broad sense, and the life-styles of the populations themselves; health-related aspects include the sphere of infectious and parasitic diseases on the one hand, and that of health care systems, their coverage and utilization, on the other. In general, relevant departments of the Ministries of Health collect the corresponding indicators; a number of them have formed the basis for the health information systems launched in connection with the implementation of the policy of primary health care in the s, which was updated in WHO ; a.
The concept of "caring" relates to both caring at family level and broader aspects of social solidarity and protection at the community or national level. It thus covers the whole range of mother-and-child caring practices, since mothers and infants are the main groups at risk, but also includes attitudes and practices of other household or community members towards those most vulnerable socially regarding time available, food distribution, emotional and material support and the level of education of care providers in general.
Indicators of this type are seldom collected regularly, when they do exist, they tend not to be easily accessible on a clearly identified central level. Thus the available information usually has to be complemented through specific community surveys, focusing especially on qualitative aspects. Yet the most fundamental causes of malnutrition and mortality very often lie outside the field of nutrition and the chains of causes briefly reviewed above: Fundamental agro-ecological and socio-economic indicators therefore also need to be included in any causal analysis of a nutrition situation at national level.
They are generally available from the major Ministries, particularly those in charge of planning. Designing a programme consists of defining material and human resources to be mobilised, in what way, for what purpose, and how, ultimately, this will alter the initial situation.
Monitoring these policies and programmes will therefore require three different types of evaluations , namely monitoring implementation of programmes, evaluation of programme impact, and, keeping track of general trends in the nutritional situation.
This deals with the assessment of programme activities, in other words the extent to which operational objectives are met. Indeed, in order to make sure that the programme contributed to changing the situation, we must first know whether it was implemented according to plans.
This assessment is based on indicators of programme implementation developed from the conception of the programme and monitored for partial or full achievement at each stage of the programme. Programmes are composed of a series of operations, each with a specific goal. To each operation corresponds a set of indicators whereby the quantity or quality of the operation can be assessed. Under a programme to promote healthier life-styles and eating habits, a country has decided to implement activities to produce training material and to carry out educational campaigns.
The implementation indicators that were adopted focused on the number and quality of educational materials produced, the number of training workshops held and teachers thus recruited, and the number of promotion campaigns carried out, associations set up and situation reports produced by those in charge throughout implementation of the programme, etc. These indicators may concern the extent to which the target population is covered by the programme, the number of training sessions organized, the percentage of households who benefited from access to the various services set up for them, etc.
In general, these indicators are specific and easy to identify, if the activities to be accomplished, which they should reflect, have been correctly defined; they are completely dependent on the specific operational aspects of the programme and therefore cannot be defined independently, in advance, based on a general framework.
Extensive use is therefore made of qualitative indicators inasmuch as the quality of activities is measured as well as their level of implementation. This type of assessment and the corresponding implementation indicators are outside the scope of this guide.
Indicators of outcomes and of impact are used here in order to measure the effectiveness of the programme - its ability to modify the situation at the beneficiary level - as well as any possible undesired effects, whether anticipated or not.
The evaluation of a programme is commonly based on a longitudinal comparison of indicators before and after implementation of the programme before-after comparison. However, unless the programmes are highly specific and narrowly targeted, interpretation may be difficult, since factors other than those introduced or changed by the programme known as confounding factors may have varied at the same time and contributed to the apparent effect of the programme. If conditions fluctuate over time change of climatic conditions, food production varying from one year to another , if the measurements are carried out at very long intervals, or if the planned intervention is general in nature, attributing the effects observed to the programme alone becomes increasingly difficult.
In the framework of a programme aimed at reducing the prevalence of undernutrition, analysis of the context revealed that diarrheal diseases were one of the main associated factors. A sub-programme was therefore set up to reduce the incidence of diarrheal diseases among young children.
One of its components was the use of oral rehydration solution ORS , and the other involved an information campaign on how to improve environmental hygiene. One of the undesirable effects that the programme had to assess was the risk that the rehydration solutions would be prepared incorrectly or unhygienically. Concerning improvements in environmental hygiene, the programme recorded indicators relating to: Changes achieved in terms of health status reduction in the incidence of diarrhea per child per year, improvement in the nutritional status of young children were selected as final impact indicators.
If the programme consists of scaling up an intervention that has proved effective elsewhere, at experimental level, the causal interpretation is simplified. If it is based on strong, but as yet unverified, hypotheses, it is more difficult to automatically attribute the observed effects to the intervention . Insofar, however, as indicators of different confounding factors likely to influence the situation were recorded before and after the implementation of the programme, statistical adjustments may be used during the analysis to improve interpretation - hence the importance of collecting these additional indicators.
A with-without comparison can then be made between two areas, one benefiting from the programme and the other not external control group. This poses the problem of initial comparability of the two areas: Alternatively, two areas may be compared with an unequal level of implementation of the programme internal control group or, more simply still, groups of individuals or households may be compared which have not benefited of the programme at the same level, since the level to which target individuals are reached by programmes is generally variable.
Ideally, the impact evaluation should follow an experimental design, with randomization of the individuals or areas to receive or not the intervention. This is the most rigorous way to proceed in order to be able to conclude on the actual impact of the intervention.
In most cases, an impact evaluation of the crude effect will be quite acceptable, i. Elements suggesting a cause and effect relationship can be formulated, but without seeking absolute proof, if plausibility of the effectiveness of the programme appears sufficient to those in charge. In , Vietnam implemented a national strategy of supplementation with vitamin A capsules through health centres to combat xerophthalmia. Three years later, an evaluation recorded a very high coverage of the populations at risk by the programme and, in addition, did not observe any clinical case of xerophthalmia based on a nationally representative sample of pre-school children.
In this case, there is little doubt that the result is directly linked to the programme, even if the evaluation cannot formally prove it: Plausibility of the link is very strong here. On the other hand, during the same period another country launched a programme to improve household food security, encompassing a certain number of measures such as the support to farm-gate prices for food crops and a reorganization of local markets on the basis of previously identified weaknesses.
The evaluation of the programme after several years of operation showed a slight improvement in the situation. Without a rigorous evaluation design, it is impossible to evaluate the relative share of improvement due to the programme or to other factors. These elements will be useful each time it has to be decided whether the programme should be continued or not.
A group of convergent elements based on the available indicators will be established in order to reach a conclusion on its likely effectiveness. Often, for financial reasons, a programme cannot be implemented straight away in all the targeted areas; these will be incorporated into the programme gradually. However, the necessary indicators can usefully be collected in all the zones from the start, for this will provide elements for comparisons between zones with and without the programme and before and after the programme, which will in turn be useful to document the plausibility of effectiveness of the intervention.
This will make it easier to evaluate the sustainability of the programme by measuring the effect simultaneously in areas where the programme has been in operation for increasing durations. The purpose of an evaluation is not only to measure impact, but also to allow the programme to be adapted to changing conditions.
An early warning system will be evaluated primarily on its ability to foresee any worsening in the consequences of food crises among the groups most at risk; it will thus comprise a number of indicators on the strategies implemented according to the degree of vulnerability, on the levels of food consumption and on the nutritional status of these groups, for example.
However, it will also involve indicators to assess whether the situation is evolving towards greater stability improvement of climatic conditions or of food production, for example so that the primary objective of the programme can be refocused if the initial goal has become obsolete. When evaluating programmes, a distinction is made in practice between impact which is the direct result of the programme, and longer term benefits, which encompass the indirect effects of the programme on the target population, or indeed the whole population, in terms of health, economic and social situation.
In the case of an isolated programme, attention may be focused on its specific impact, but in the context of overall monitoring of a policy or group of programmes, the impact of the complete set of strategies will be the subject of regular evaluation - which will aim not so much at providing evidence of the effectiveness of one or another programme, but rather at verifying whether the situation is evolving in the desired direction, taking into account external circumstances and the programmes in operation.
Apart from regular measurement of progress, this will also provide an opportunity to check that the conceptual analysis on which the choice of different strategies was based is still relevant, or to see whether activities need refocusing.
The aim is to examine changes in the situation in terms of the general objectives of the policy adopted, implying regular collection of a certain number of indicators of risk and of causes, as well as major basic indicators, to be used by country planners and by international agencies or donors, and assessment of trends.
This corresponds to one of the nine strategies proposed in by the ICN Plan of Action - which has been taken up since then by a number of countries for their national action plan - that of "assessing, analysing and monitoring nutrition situations". This implies setting up a proper nutrition surveillance system applied to planning.
These national plans have explicit general goals with an order of magnitude for expected reductions in malnutrition levels or improvements in various sectors. As a result of its plan, Ecuador, like other countries, anticipates fulfilling the following objectives in terms of improvements in the nutritional status of the population: Objectives will be all the more explicit and realistic if there is a recent "baseline" and an idea of trends in the past or in neighbouring countries or in countries with similar constraints.
However, waiting for a complete baseline to be available would not be reasonable; one can start with existing data from the various services, or with rapid surveys carried out on a one-off basis when there are no data for a specific problem deemed to be important. Yet implementing a policy must be an opportunity for also setting up a monitoring system - covering at least the main indicators of status and causes of malnutrition, which will be put in perspective with major agro-ecological and socio-economic indicators - in order to have an ongoing "log-book" of the situation and of time trends.
After analysis, a country considers that the prevalence of low birthweight is too high and that the goal of reducing it implies i strengthening the performance of pre-natal health care services, ii promoting a better diet for mothers-to-be, either through better use of local food or the specific distribution of food supplements, and iii encouraging a reduction in the workload of pregnant women through various measures.
The precise actions to be undertaken and any precise quantification in terms of intermediate objectives depend of course on the specific country situation. Monitoring implementation of these actions will be based on a quantitative and qualitative assessment of the performance level of the units concerned number of rations distributed or number of persons who have used the services, percentage of services which have given advice and care of adequate quality to pregnant women, quality of rations distributed, level of use of the advice and care by the beneficiaries, etc.
At programme evaluation, outcomes and impact indicators can be based on changes in the frequency of consumption of certain foods by the women attending the units, or on changes in average birth weight and prevalence of low birth weight in the target population. Indicators do not all have the same value. In theory this depends on their ability to best reflect a sometimes complex reality, but a trade-off will have to be found given the level of difficulty in collecting them.
Therefore, indicators are traditionally defined according to a certain number of properties that allow their value to be assessed, at least in a given context. Obviously they do not all present all the characteristics of a good indicator, so that it will have to be decided which characteristics are to be given priority when selecting indicators. It entails that the indicator does indeed offer a true and as direct as possible measurement of the phenomenon considered.
At conceptual level, it depends first of all on how clearly the phenomenon to be measured has been defined and also on the ability to measure it directly. This poses a problem where the phenomenon to be measured is linked to a multidimensional concept, and is thus difficult to measure in a global way. There must, in particular, be a consensus on the level and significance of cut-off points for classification.
A major standardization effort has for example been made in the field of measuring nutritional status and recommended dietary intakes, and this has helped give a more precise framework for use of the corresponding indicators. This is not always the case in other sectors, either because the indicators lend themselves less to quantification, or because such quantification depends very much on local circumstances. Relevance in the context of planned use must, in this case, be based on a local analysis shared among the different stakeholders, as we will see below.
Moreover, even if the indicator correctly describes a phenomenon, any systematic bias in collecting the corresponding information due to measurement methods or instruments will affect its validity. There is no overall indicator to provide a picture of "nutritional status", therefore a decision has to be made on which specific aspect of nutritional status is to be characterized: Even in the case of energy status, for example, no overall indicator is available; the indicator which is the most relevant for the aspect one wishes to prioritise - physical, biochemical, functional, etc.
For assessing the nutritional situation of a population, a set of individual anthropometric measurements have been adopted, that, when compared to reference values, make it possible to assess the status of individuals or populations; they constitute the corpus of relevant indicators to be used preferably over any other. However, when using these indicators, one should be aware of limitations to their validity: In the field of "food security", - again a very broad concept difficult to translate in simple terms - there is a considerable number of indicators, each reflecting a specific aspect and thus only relevant for a given aspect.
For example, in order to describe the level of food insecurity of a household, an indicator based on a quantitative criterion of food consumption or a qualitative criterion of the perception by the household of its own food insecurity situation will be more relevant than an indicator of prices of foodstuffs on the local market.
Imprecision due to measurement methods, variability from one day to another may limit the reproducibility of the indicator. This causes an increase in variance and implies that larger samples will be needed in order to assess correctly the level of the indicator and its variations over time.
Subjectivity bias is a frequent risk with indicators deriving from qualitative surveys, as they describe behaviours or opinions of households, for example, since the personality or technique of the person conducting the survey may influence the nature of responses. Moreover, respondents to a questionnaire or subjects under observation can modify their responses or behaviour in a normative way. People who are overweight, for example, often minimise their actual food intake when interviewed for a food consumption survey.
Reproducibility guarantees that an indicator can be measured at repeated intervals in a comparable manner - a quality which is crucial when using the indicator to assess and monitor the situation.
A complementary characteristic is specificity, which refers to the ability to identify those not affected by the risk or characteristic. Sensitivity is measured in practice by the ratio of the number of individuals identified by the indicator as being at risk or as having the characteristic to the number of individuals who are actually at risk or have the characteristic.