NUTRITION INFORMATION Sri Lanka

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NUTRITION INFORMATION SYSTEM IN SRI LANKA

Dr. Renuka Jayatissa
(M.B.B.S., M.Sc, MD)

Department of Nutrition Medical Research Institute

Department of Health services Sri Lanka in collaboration with WORLD BANK 2002

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CONTENTS
Acknowledgements Chapter 1: Introduction……………………………………………………………... Chapter 2: Development of NIS.…..………………………………………………. Chapter 3: Findings of the baseline information ………………….……………. Chapter 4: Establishment of NIS and use of information …………………………. Chapter 5: References ……………………………………………………………… Annex 1: Annex 2: 3 4 6 15 44 49 51 52

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ACKNOWLEDGEMENTS I wish to thank WORLD BANK for providing the funds to conduct the study. Special mention must be made of Dr. Amarasinghe, Co-ordinator, World Bank project for the speedy course of action taken to release funds. The members of the Technical Advisory Committee provided an invaluable service in planning the study. I thank them. I sincerely thank Dr. C.D. Gunaratne, Director Nutrition, Dept. of Health, Colombo, for all the support, Prof. Lalani Rajapaksa, Department of Community Medicine, Faculty of Medicine, Colombo and Mrs. Soma de Silva, UNICEF for providing their expertise in selecting the sample for the study and Prof. Dulitha Fernando, Professor of Community Medicine, Faculty of Medicine, Colombo, assisted in the preparation of the Report. I am grateful to Dr.Gaya Colambage, Director, Medical Research Institute. She gave her best to make the study a success. Last, but foremost in mind are the pivotal operators: the Provincial Directors, Principals of the schools, teachers, parents, and children. To one and all I wish to say am deeply indebted to you for having been partners in the study.

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CHAPTER 1 INTRODUCTION
Sri Lanka is an island with a population of approximately 18.7 million. For purposes of administration, Sri Lanka is divided into 8 Provinces, 25 Districts and 315 Divisional Secretary areas. The Eight Provincial Directors of Health Services (PDHS) are totally responsible for management and effective implementation of health services in the respective provinces. Deputy Provincial Directors of Health Services (DPDHS) assist the eight PDHSs. DPDHS areas are similar to administrative districts, except for Kilinochchi and Ampara district. Each DPDHS area is sub-divided into several Medical Officers of Health areas (MOH/DDHS), which are congruent with administrative units, i.e. Divisional Secretariats. The MOH/DDHS is responsible for the preventive and promotional health care in a defined area, with a population ranging from 60,000 to 80,000 and has trained staff working at field level (Annual Health Bulletin, 2000). Though Sri Lanka has achieved considerable success in the reduction of mortality with increase in the life expectancy, the load of morbidity that is present in the community has not been commensurate with the decline in mortality. An important and persisting problem has been the significant level of malnutrition, affecting particularly infants, children of the younger age groups and pregnant women. Though poverty does influence levels of under nutrition, poverty alone does not explain the high prevalence of underweight that persists in Sri Lanka. Educational and cultural factors are likely to play a significant role, which in turn affect infant and child feeding practices and family attitudes towards nutrition in general (Ministry of Health Highways and Social services, 1995). Nutrition information system (NIS) is a system designed to monitor, on a continuous and regular basis, the food and nutrition situation of a country. It will watch over nutrition in order to make decisions, which will in turn lead to improvements in nutrition in the population. Sri Lanka is relatively rich in nutrition relevant data that can be used to build nutrition information system. There is a lot of information collected routinely in the health sector by different categories of staff and different agencies at different times. However, it is important to find out what information is really needed to assess the nutritional problems in the community and what information is related to causality. The micro level assessment of nutritional factors are very important to counteract the action oriented cycle because the decisions can be taken at community level by the information collectors themselves rather than waiting till the national interventions arrived.

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The following elements exist at present as nutrition information;     Food balance sheet Data on growth monitoring, Data on health indicators (birth weight, disease pattern) - Health Maternal and child health data - Health - Statistics Department - Health

In addition to the above survey data are also available, e.g.,     Socio-economic survey data National Health survey Anaemia, Iodine, Vit A surveys Central Bank Department of Census and Statistics Ministry of Policy Planning Medical Research Institute Demographic and health survey data -

This is an analysis to show how we can use the routinely collected information and survey data as an action oriented basis. It will be useful to Health workers, Medical officers of Health, Deputy Provincial Directors, Provincial Directors and Nationally, to assess the situation and the monitoring and evaluating of interventions to eliminate the nutritional problems in the country. In turn, this type of exercise will help to improve the accuracy and quality of routinely collected data. The objectives of the nutrition information system are as follows: General objectives: 1. To develop a Nutrition Information System (NIS) with minimal additional inputs. Specific objectives: 1. To assess the nutritional status using a life style approach;

• • • • •

children under 5 years school children adolescents adults pregnant women

2. To develop indicators relevant to nutritional problems 3. To identify trends in nutritional status and analyse associated factors 4. To make recommendations regarding activities that should be undertaken to established a surveillance system at MOH, district and provincial level.

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CHAPTER 2 DEVELOPMENT OF NIS It was decided to study the nutritional problems using a life style approach. The following steps were adopted to collect information to develop the NIS, i.e., 1. Identification of information to be included in the NIS 2. Discussion with Experts 3. Collection of available information 4. Collection of information on children aged 5-14 years. Figure 1 Conceptual Framework for the Causes of Malnutrition in Society
Malnutrition and death

Outcomes

Inadequate dietary intake

Disease

Immediate causes

Inadequate access to food

Inadequate care for mothers and children

Insufficient health services and unhealthy environment

Underlying Inadequate Education causes

Formal and non formal institutions

Basic causes

Political and ideological superstructure

Economic structure

Potential resources

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2.1. Identification of information to be included in the NIS Conceptual framework of the causes of malnutrition was used to facilitate the identification of data on assessment and analysis of the determinants of malnutrition (UNICEF 1990). The framework is shown in Figure 1. In this framework, casual factors and their interactions are shown at three mains societal levelsimmediate, underlying and basic. The synergistic interaction between the two immediate causes, inadequate dietary intake and disease, fuels a vicious cycle that accounts for much of the high morbidity and mortality. Three groups of underlying factors contribute to inadequate dietary intake and infectious disease: household food insecurity, inadequate maternal and childcare and poor health services, and an unhealthy environment. These underlying causes are in turn underpinned by basic causes that relate to the amount, quality, control and use of various resources (United Nation 1997). The following indicators were identified to collect information on causal factors. 2.2. Discussion with Experts Core-group was formulated with Public Health specialists, Academics and other specialists with nutrition background (Annex-1). Series of discussion sessions were conducted to gather information. Major nutritional problems in Sri Lanka were identified and the following areas were prioritised.  Low birth weight  Protein energy malnutrition of children under 5 years and school children  Iron deficiency anaemia throughout the life cycle  Iodine deficiency among school children  Vitamin A deficiency among children under five years The following activities were identified under the design of the NIS.

– – – –

development of indicators relevant to each nutrition problem to make decisions. needed data for selected information. sources of data,   administrative sources (data already being gathered routinely) household surveys

Responsibility of institutions.

During the sessions of discussions the above activities were followed for the above-mentioned nutritional problems as shown in Table 1.

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Table 1 Identification of nutritional problems, indicators, source of data and responsibilities of institutions using a lifecycle approach Problem Definition of indicator Source of data    II. Stunting (6-59 months) III. Underweight (under 5 years) % of children below -2SD from the median of the NCHS/WHO height for age reference population % of children below -2SD from the median of the NCHS/WHO weight for age reference population % of children under 5 years who attended clinics and below the 3rd centile % of children below -2SD from the median of the NCHS/WHO weight for height reference population   Monthly data from FHB by DDHS area (H-509) Monthly returns from hospital Birth weight Surveillance Special surveys and surveillance at every 5 years Special surveys and surveillance at every 5 years Monthly data from FHB by DDHS area (H-509) Special surveys and surveillance at every 5 years  Responsibility D/FHB

 Children under five years 1.Low Birth % of new-borns below 2500g Weight



Director/MS/DM O/MOIC/RMO  D(FHB)/MRI Existing research data/DHS/MRI/ NHS  Existing research data/DHS/ MRI/NHS  FHB

 

IV. Wasting (under 5 years)

Existing research data/DHS/MRI/ NHS  D/FHB

 Primary school children V. Stunting at % of children below -2SD from the School entry median of the NCHS/WHO height ( year 1, 4) for age reference population

VI. Wasting (year 1,4)

% of children below -2SD from the median of the NCHS/WHO weight for height reference population

VII. Overweight (year 1,4)

% of children above +2SD from the median of the NCHS/WHO weight for height reference population

Monthly data from FHB by DDHS area (school health return)  Special surveys and surveillance at every 5 years  Monthly data from FHB by DDHS area (school health return)  Special surveys and surveillance at every 5 years  Monthly data from FHB by DDHS area (school health return) 

 

MRI D/FHB

 

MRI D/FHB

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Special surveys and  surveillance at every 5 years Monthly data from FHB by DDHS area (school health return) Special surveys and surveillance at every 5 years

MRI

 Adolescents VIII. Thinness % of adolescents below the 5th in adolescents percentile from the reference (year 7) population for under nutrition for BMI for age





D/FHB





MRI

IX. Overweight in adolescents (year 7)

% of adolescents at and above 85th percentile from the reference population for BMI for age





Monthly data from FHB by DDHS area (school health return) Special surveys and surveillance at every 5 years 



D/FHB



MRI

 Pregnant women X. % of pregnant women below 18.5 Underweight of BMI at first trimester

XI. Weight gain in pregnancy

% of pregnant women with weight gain during the pregnancy

Monthly data from FHB by DDHS area (H-509 return)  Special surveys and surveillance at every 5 years  Monthly data from FHB by DDHS area (H-509 returns to be included)  Special surveys and surveillance at every 5 years   Hospital data from health bulletin

D/FHB

 

MRI D/FHB




MRI
D/information

 Adults XII. Diet related chronic degenerative diseases XIII. Underweight

Rates of morbidity and mortality of chronic degenerative diseases: cardiovascular disease, diabetes, obesity, some cancers: comparison with some infectious disease rates % of adults below the 18.5 BMI



Special surveys and surveillance at every 5 years



MRI

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XIV. Overweight XV. Changing dietary patterns

% of adults above the 24.9 of BMI



1. Food availability by food groups in the country. 2. Per capita daily energy intake for selected food items by sector 3. Contribution of each food groups to the overall calorie intake with income

  

Special surveys and surveillance at every 5 years Food balance sheet Socio-economic survey Socio-economic survey Special surveys and surveillance at every 5 years Special surveys and surveillance at every 5 years Special surveys and surveillance at every 5 years



MRI

  

Census and statistics Central Bank Central Bank MRI

 Micro nutrient deficiencies XVI. Anaemia % of children with haemoglobin below the cut-off value. XVII. Vitamin A % of children with the prevalence deficiency of serum retinal µmol/L Mild =>0-<10% Moderate = >=10-<20 Severe = >=20 XVII. 1. % of children of 6-12 years of Iodine age with urine iodine levels deficiency<100µg/L Mild = <100-50 Moderate = <50-25 Severe = <25 2. % of children of 6-12 years in representative sample with the prevalence of total goitre (grade 1 and 2) >5% Grade 0 = Not visible and not palpable. Grade 1 = Not visible with neck in normal position. The mass moves upward when the subject swallows. Grade 2 = Swelling in the neck is visible when the neck is in a normal position and palpable. Causes of malnutrition under 5 years Dietary intake  Dietary energy consumption Diseases   incidence of diarrhoea and ARI, immunisation coverage,









MRI





MRI

  

Socio-economic survey Health Bulletin Health Bulletin 

 

Central Bank MOH

MOH

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Household food security

  

 infectious disease rates dietary energy supply; food intake relative to need, Percent below poverty line, Breast feeding (duration and percentage); Mean age of introduction of complementary foods; Usage of oral Rehydration Fluids (ORT) Coverage of measles vaccination, Births attended by a trained health staff, Availability of clean water, Availability of sanitary latrines



 Health Bulletin Socio-economic survey



MOH  Central Bank

Inadequate maternal and child care

  

      

Health Bulletin/ H509



MOH/FHB MRI FHB FHB FHB  D/Environ ment/MOH

Special surveys and  surveillance at every 5 years H-509  H-509 H-509 PHI sanitation record PHI sanitation record  

Access to basic health services

 

Healthy environment

 

The identified indicators to assess nutritional problems, source of data and responsibilities of the collection of data were finalised with Experts. Since information regarding to children less than 5 years is available at the moment, it was decided to use secondary data as baseline information. To carry out the school based study to collect information on children aged 5-18 years due to the importance of problems in that group and lack of current data. 2.3. Collection of available information Information was collected with regard to each indicator by identified data sources and literature review, including reviews of "grey" or unpublished literature and by interview with key informants. Due to the methodology adopted in the Demographic Health Survey (DHS), it was not possible to identify the prevalence of nutritional problems and the determinants by districts or provinces. Therefore other available studies were used.

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The following data was available (routine and survey data):        Children under 5 years Adults Micro nutrient deficiencies Causes of malnutrition under 5 years Primary school children Adolescence Pregnant women

Following information is not available:

Therefore simple method was adopted to collect information on primary school children and adolescence at school level. 2.4. Collection of information on children aged 5-14 years Information was collected cross-sectionaly in 7 districts of the country due to logistic reasons. The districts were selected by considering the following factors:  High and low prevalence of stunting and wasting of children under 5 years for last 20 years  Prevalence of stunting/ wasting/ underweight has not been changed much during the last 20 years.  Prevalence of Vitamin A deficiency in the area  Prevalence of anaemia in the area  Deficiency of iodine in the area  Presence of representative data by district and Province. The following districts were selected.  Anuradhapura, Polonnaruwa, Badulla, Moneragala, Colombo, Hambantota, Kurunagala.

2.4.1. Data collection Data were collected among school children aged 5-14 years because 90% of children belonged to the particular age group could easily met in the schools. The required sample size for each district was calculated on the basis of the prevalence of underweight among children less than 5 years. This was 800 children from 5-14 year old age group giving a total sample size of 5600 for all 7 districts. The schools were selected from a list of all schools in Sri Lanka that was provided by the Department of Education. A multi-stage stratified sampling technique was used to identify the sample. During the first stage the proportionate stratification was done to identify the number of schools in the urban and rural areas in

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each district according to the population of children in selected age group. In the second stage, types of schools were considered. During the third stage, required number of schools was identified using population proportion to sampling technique. During the fourth stage of sampling, all classes of grade 1, 4 and 7 were listed out and one class from each grade was randomly selected from each school. Grade 1,4 and 7 was selected to study by considering the school health programme in the country to adopt that data into the NIS in the future. All the children in each selected class were included in the assessment nutritional status. The following information was obtained: 1. Basic information: birthday and sex and other identifying information 2. Biochemical assessment for anaemia 3. Measurement of height and weight 2.4.1.1. Basic information All children in selected classes who had obtained the consent of their parents and were present on the day of the study were identified as participants. A structured format was developed to obtain identification data, age and sex of children in the selected classes. The information was obtained from the attendance register and marked on the format by a member of the study team. 2.4.2.2. Biochemical assessment for anaemia Sample of capillary blood for estimating haemoglobin was obtained from 10 children, selected at random from each selected class (grade 1,4 and 7) in each school. Haemoglobin was assessed by Haemocue method. A total of 30 haemoglobin from each school was estimated. The following procedure was used to detect anaemia by using HaemoCue method: A finger-pricked drop of capillary blood was taken by using a disposable lancet. The function of the HaemoCue photometer was checked on a daily basis by measuring the control cuvette. 2.4.2.3. Measurement for height and weight All the children in selected classes were measured for height and weight. Measurements were taken by the field investigators who had been trained and standardised before the study. Height was recorded to the nearest centimetre by using anthropometrics rod. The children were weighed with the use of an electronic balance to the nearest 0.01kg after they removed their shoes and socks. The observer

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variation was assessed by duplicating the measurement by the same observer and repeating the 10% by the best investigator. 2.3.2. Field level activities The field investigators, all of whom have previous experience in field research activities, were responsible for all components of the study (Annex-2). Investigators were trained in testing the capillary blood samples for haemoglobin content. All selected schools were informed about the study. The consent forms were distributed to all children in the selected classes prior to the study to obtain the consent of the parents/guardians. The schools were informed of the date of the visit. All fieldwork was completed during a 6-month period, November 2001 - April 2002. 2.3.3. Collection of data in Colombo district: Five schools from urban sector were covered by the study team. Rural sector schools were not studied due to the school vacation.

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CHAPTER 3 Findings of the baseline information
A nutrition information system requires; correct assessment of the problem; an appropriate analysis of the causes of the problem on a provincial or district basis; and the resources available to combat the problem. Based on these causes of the problems and the resource analysis, action would then be taken and the results, including the achievements of a particular desirable outcome, measured. This would in turn provide an opportunity for further analysis and better action to improve the nutrition situation -"Triple A cycle" (Asian Development Bank 1999). 3.1. Assessment of the problem The results are presented according to the following order by considering the lifecycle approach: low birth weight, protein energy malnutrition (PEM) of children under 5 years, nutritional problems among school children, nutritional problems among adults, Vitamin A deficiency, iodine deficiency. This section includes a presentation of prevalence and trends of the nutritional status. 3.1.1. LOW BIRTH WEIGHT Most children are born with low birth weight and become increasingly malnourished. Figure 2 shows that the highest low birth weight is in the Central Province and then in Uva Province. The lowest is in Western Province. But it had declined in all the Provinces.
Figure 2 Tre nds in pre v ale nce of Low Birth We ight in Prov ince s of Sri Lanka, 1975-2000
(Source: Annual Health Bulletin 1984-2000, Ministry of Policy planning 1988/89) 80 70 60 50

Central North central Sabaragamuwa Uva Southern North Western Western Eastern

%

40 30 20 10 0 1984 1988-89 1991 Year 1992 1993 2000

Nothern

Figure 3 and 4 shows the geographical distribution of the prevalence of low birth weight. Annual health bulletin provides the registrar General's data, which are originally taken from hospital statistics and not validated, for districts. Therefore this data should be interpreted cautiously. WHO (1995) recommended,

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prevalence of >15% of LBW as the cut-off for triggering public health action. Therefore the arbitrary cutoffs were used as <10%, 10-14, 15-19 and >=20% as low, moderate, high and very high prevalence of LBW in the population. The very high prevalence was detected in NuwaraEliya, Badulla, Monaragala and Batticaloe districts. Almost all the districts show the prevalence higher than 10%. When the data was compared with the 1988/89, an improvement was detected in some districts like Polonnaruwa, Matale, and Puttulum etc. Figure 3 and 4 Prevalence of low birth weight by district, 1988-2000
(Source: Ministry of policy planning 1988/89 and Annual health bulletin 2000)

3.1.2. PROTEIN ENERGY MALNUTRITION OF CHILDREN UNDER 5 YEARS

Figure 5 Child malnutrition (0-4.99 years) in Sri Lanka, 1975-2000

Percentage below median (-2SD)

70 60 50 40 30 20 10 0

Underweight Stunting Wasting

1975-76

1977-78

1980-82

1995-96

1987

1993

Year

2000

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As shown in Figure 5, stunting among Sri Lankan children has improved from 49.9% to 13.5% since 1975 but wasting has not improved during this period, i.e. 13.9% to 14%. Though the underweight is a complex index to interpret it has also declined from 57.3% to 29.4%.
Figure 6 Trends in prevalence of Child stunting (0-4.99 years) in Provinces of Sri Lanka, 1980-1995
(Source:Ministry of policy planning 1980/2,1988/9 and MRI 1998) 60

Percentage below median (-2SD)

50 40 30 20 10 0 1980-82 1988-89 1995 Year

Central North central Sabaragamuwa Uva Southern North Western Western

There are wide variations in the prevalence of stunting and wasting among the different Provinces in Sri Lanka, the Uva Province having the highest rate of stunting and the Western Province having the lowest. But all the Provinces have shown a marked improvement (Figure 6). Wasting among children has increased in Sabaragamuwa Province. But in all other Provinces it has gone up in 1988/89 and come down to the 1980-82 level in 1995. There has been no improvement at all in the North Western Province since 1980 (Figure 7).
Figure 7 Trends in prevalence of Child wasting (0-4.99 years) in Provinces of Sri Lanka, 1980-2000
25 Central North central Sabaragamuwa Uva 15 Southern North Western 10 Western

Percentage below median (-2SD)

20

5

0 1980-82 1988-89 1995 Year

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Figure 8 and 9 Prevalence of stunting among children less than 5 years by district, 1987-2001
(Source: Ministry of policy planning 1988/89 and MRI 2001-unpublished )

The prevalence of wasting and stunting by districts were mapped out to assess the problem at micro level. The degree of stunting and wasting was classified as low, moderate, high and very high to assess the severity of malnutrition in the provinces and districts (the classification currently used by WHO Global database was taken). As the district data is not available after the year 1988/89 the unpublished data on the anaemia status survey report was analysed by district to be used but this data are not representative of district. Therefore this information should be interpreted cautiously. It is interesting to note that the level of stunting ranges from low to high and that very high level of stunting is not detected at present. NuwaraEliya district still shows a high level of stunting. The reason may be due to the fact that in this district whose population consists of estate workers, infrastructure is lacking when compared to other districts. Kandy, Badulla and Monaragala districts have a moderate degree of stunting and the rest of the districts have a low degree of stunting. When these findings are compared with 1988/89 data, it shows a tremendous improvement. However, the geographical distribution of stunting and low birth weights by districts are compared (Figure 4 and 9), it showed somewhat similar distribution. Low birth rate may be a causal factor for the stunting.

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Figure 10 and 11 Prevalence of wasting among children less than 5 years by district, 1987-2001 (Source: Ministry of
policy planning 1988/89 and MRI 2001-unpublished)

In 1988/9, most of the districts had a very high level of wasting except in 5 districts. At present there is a marked improvement and only 6 districts still maintain a very high level of wasting. Gampaha district has changed from a high degree of wasting to medium degree of wasting and Matale district has changed from very high level to a low level of wasting during the last 13 years (this observation may be related to low sample size in Matale district in 2001). Though the national level of wasting has not got changed, the district level improvements are remarkable. At present, more concentration should be focussed on the districts, which still maintain very high levels of wasting, i.e., Kurunagala, Anuradhapura, Polonnaruwa, Kandy, Monaragala and Hambantota.

3.1.3. NUTRITIONAL PROBLEMS AMONG SCHOOL CHILDREN The data were collected from 7687 school children in 7 districts. Two age groups were identified and classified into groups, primary school children (5-9.9 years) and adolescents (10-14.9 years). Number of children in each age group was 4876 (63.4%) and 2811 (36.6%). 3.1.3.1. UNDER NUTRITION I. Primary school children The nutritional status was assessed by calculating the wasting and stunting of children aged 5-9.9 years and it was graded according to WHO classification and shown in the Figure 12 and 13 to illustrate the geographical distribution.

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Figure 12 and 13 Prevalence of stunting and wasting among school children aged 5-9.9 years by districts, 2002

Badulla district has moderate degree of stunting and it is the highest rate reported in this school study. All the other districts surveyed have mild degree of stunting. These findings are comparative with the stunting rates among children under 5 years of age except in Monaragala district, which showed a moderate degree of stunting prevalence among children less than 5 years (Figure 12). In that case it is interesting to note that there is an improvement of stunting from pre-school to school children in Monaragala district. Figure 13 shows the wasting prevalence in the surveyed districts. A very high grade of wasting has been found in Kurunagala, Monaragala and Hambantota districts according to the population prevalence. All the other districts, which were studied, also have a high degree of wasting. A similar pattern is observed when we compare this with the wasting prevalence among children less than 5 years. In Anuradhapura district of course, there is a difference. There is a shifting from very high prevalence to high prevalence from pre-school to school (Figure 11). II. Adolescents When NCHS/WHO reference was applied to classify the under nutrition and over nutrition among adolescents, 44.7% and 84.0% of records in the studied population was flagged at the age of 10 years and 11 years respectively. Therefore the BMI-for-age-sex was taken as a reference and thinness was calculated by districts and shown in Figure 14.

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Figure 14 Prevalence of thinness among schoolchildren aged 10-14.9 years by district, 2002 The proportion of the population with thinness was classified by WHO (1995) as low, medium, high and very high prevalence to classify the severity of the thinness. It would also define a public health problem and this classification is closely linked to available resources for correcting problems, the stability of the environment and government priorities (Figure 14). Hambantota district has shown a very high level of thinness and all the other districts studied have indicated high level. It is interesting to note that this observation is comparative with the pattern observed among primary school children except in Monaragala and Kurunagala districts. In these districts there is an improvement from very high level to high level from primary school to adolescents. This finding indicates that when children are close, at, or passing the growth spurt they have caught up the growth. 3.1.3.2. OVER NUTRITION I. Primary school children and adolescents Primary school children whose Wt/Ht is >2SD in the NCHS/WHO reference and the adolescents whose BMI>=85th percentile in WHO 1995 reference, was classified as overweight children. Geographical distribution is shown in Figure 15 and 16. The proportion of the school children with overweight was classified by taking arbitrary cut-off points to reflect the distribution of overweight among children as shown in Figure 15 and 16 (low, medium, high and very high prevalence). In this study it was found that there is low prevalence in all the districts studied except in Colombo district. Figure 16 shows the increasing pattern among adolescents. Colombo district has a very high level of overweight prevalence among adolescents’ children. But it showed a medium prevalence with primary schoolchildren. Even the Badulla and Polonnaruwa districts have increasing trends from low to high prevalence. This is a situation to be aware of with the decreasing trend of under nutrition in the country.

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Figure 15 and 16 Prevalence of overweight among schoolchildren aged 5-9.9 years and 10-14.9 years by district in year 2002

3.1.3.3. ANAEMIA Anaemia was assessed by measuring haemoglobin levels of school children. Total number of children tested for anaemia was 1448 and 766 from primary school children and adolescents respectively. Age dependent haemoglobin levels were taken to detect anaemia by adjusting the altitude. The proportion of the school children with anaemia was classified by taking WHO cut-off points to reflect the distribution of anaemia among children as shown in Figure 17 and 18 (low, medium, high and very high prevalence). Figure 17 and 18 Prevalence of anaemia among schoolchildren aged 5-9.9 years and 10-14.9 years by district in year 2002

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Very high levels of anaemia were not seen in any district. A high degree of anaemia has been shown in Anuradhpura and Kurunagala districts. Thalasaemia is more prevalent in these districts. When it comes to the adolescent group Colombo district has a low level of anaemia and other districts have a medium level of anaemia prevalence. 3.1.4. NUTRITIONAL PROBLEMS AMONG ADULTS 3.1.4.1. Diet related chronic degenerative diseases among adults The most prominent chronic degenerative diseases - cardiovascular disease, cancer and diabetes mellitus - are linked by unhealthy diet and physical inactivity. Actions to prevent these diseases should, therefore, focus on controlling the risk factors in an integrated manner. Therefore the disease pattern and causal factors are analysed under selected indicators. 3.1.4.1.i. Morbidity and mortality rates among major chronic degenerative diseases There is an upward trend of Diabetes Mellitus, Hypertension and Ischaemic Heart disease among hospital admissions and in contrast to that there is a downward trend in helminthiasis and vitamin deficiencies and intestinal infections (Figure 19). This pattern clearly shows the double burden of diseases in Sri Lanka. At one end diseases related to poverty and at the other end diseases due to prosperity.
Figure 19 Trends in Hospitalisation of selected diseases in Sri Lanka, 1975-2000 ( Source:Health bulletin – 2000 ) Intestinal infec dis Helminthiasi s Nutr. Defi.
Diabetes Hypertension IHD

1200

1000

Cases per 100,000 population

800

600

400

200

0 1975 1980 1985 1990 1995 2000

Year

(Exclude: Jaffna, Kilinochchi, Mullativu and Ampara Districts)

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3.1.4.1.ii. Changing dietary patterns The eating habits of people are changing. More people are eating out more frequently or eating foods that are not nutritionally balanced. They are consuming more of animal fats, sugar and fried foods and less of fresh fruits and vegetables (WHO 2001).
Oils & Fats Figure 20 Milk Change s in pe rcapita av ailability of foods Fish (gms/day) in Sri Lanka, 1982-1999
1000 900 800 700
Gms/day

(Source: Food balance sheets 1982-1999)

Eggs Meat

Fruits Vegetables Pulses & Nuts Sugar Roots & Tubers Cereals

600 500 400 300 200 100 0 1982 1984 1991 1995 1997 1999

Year

Food availability in Sri Lanka since last two decades clearly shows this changing pattern (Figure 20). The availability is directly related to the consumption pattern of the population. The oils, fats, sugar and meat availability has increased in contrast to the decreased trend of the availability of pulses, nuts. Vegetable and fruit availability has not changed much during this period.
Figure 21 Contribution from urban, rural and e state se ctors (% of de aths) from dise ase s of the circulatory syste m in 1991 in male s and fe male s 80 60
%
(Source:Cardiov ascular research in Sri Lanka 1998)
Male Female

40 20 0
Urban Rural Estate Sector

25

NIS/MRI

The mortality rates due to diseases of the circulatory system by sector suggest a higher mortality rate among urban population than among rural and estate population (Figure 21). When we compare this finding with per capita daily energy intake for selected food items, it shows that the urban population consumes more animal food like meat, fish, sugar and milk than rural and estate population (Figure 22).

Figure 22 Per capita daily energy consumption of selected Others food items by sector
(Source: Socio-economic finance survey 1996/97) Vegetable Meat,Fish,Milk

100% 80%
% of energy
Sugar

60%
Coconut

40% 20% 0% Urban Rural Estate

Wheat Flour and Bread Rice

Sector

Coconut consumption is highest among rural population. This findings support the study carried out among Polynesian islanders who obtain 34-63% of their food energy from coconut and found vascular diseases uncommon among them (Prior 1981). Though the vegetable is grown in the estate sector, the vegetable consumption is lowest among the estate population.

Figure 23 Components of diet in re lation to income de ciles of spe nding units
(Source: Consumer finance and socio economic survey 1996-97)

100% 80%
% of energy
Others Carbohydrate Animal Fat Vegetable Fat

60% 40% 20% 0%
Income deciles of spending units

10

1

2

3

4

5

6

7

8

9

26

NIS/MRI

When the contribution of each food group to the overall calorie intake with rising income shows a marked variation (Figure 23). The spending units at the upper income deciles derived higher proportion of animal fat compared to others. In contrast, the lower deciles derived more energy from vegetable fat. Rice, bread and wheat flour accounted for the highest proportion of energy derived for all groups. 3.1.4.2. Overweight and obesity Inactive life is attributed to high body mass index (BMI) and the high rate of overweight and obesity in the society. The changing pattern of prevalence of overweight among males and females in different age groups in urban areas is illustrated in Figure 24. Though the study methodologies were not comparative, it showed the high prevalence of overweight among females than males. The prevalence of overweight is more among the 40-49 year age group. From then the reducing trend of overweight has observed. This is an alarming situation when compared with the increasing trend of noncommunicable diseases. This is one of the issues to be addressed urgently.
Figure 24 Pre v ale nce of ov e rwe ight and obe sity among male s and fe male s, 1993-2001
% 50 45 40 35 30 25 20 15 10 5 0 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 >=60 Age groups

(Source: MRI, Lipid profile study 1993 & MRI 2002)
Male overweight 2001 male overweight Female overweight 2001 female overweight Male obese 2001 male obesity Female obesity 2001 female obesity

27

NIS/MRI

3.1.4.3. Underweight Figure 25 Prevalence of underweight among adults over 40 years of age in different populations, 2001 (Jayatissa 2002-unpublished,n=720)
underweight %

35 30 25 20 15 10 5 0

28.6

16.3 11.2 9.4

Rural

Office workers

Semiurban

Population categories

The prevalence of underweight is also high among adults especially in the rural population. Figure 25 shows that the proportion of underweight is decreasing with the urbanisation. There are no existing programmes to address this problem.

3.1.5. VITAMIN A DEFICIENCY STATUS (VAD) The clinical signs of VAD include night blindness, Bitot’s spots, corneal xerosis and corneal scars or ulcers. The prevalence of clinical deficiency is estimated by combining night blindness and eye changes, primarily Bitot’s spot to form a “total Xerophthalmia” prevalence (United Nation 2001). Clinical VAD assessed by eye deficiency (Xerophthalmia) is considered a public health problem at more than 1% prevalence (Asian Development Bank 1999). The trend in clinical VAD prevalence was assessed in Sri Lanka from 1975 to 1996. It has reduced from 1.1% in 1975 to 0.3% in 1987 and 0.8% in 1995/96. It showed there is an improvement of clinical VAD. The provincial estimates from previous surveys since 1975 was compared (Table 1). The improving trend is apparent, except in the Western Province. When the provincial trends are taken into consideration, we can see that the clinical VAD is a public health problem in the Southern and the Sabaragamuwa Provinces in 1995, but not in the whole country. It is noted that the sub clinical VAD is increasing. Sub clinical VAD is defined as the prevalence of serum retinol concentration below 0.70 mmol/l (20 g/dl) minus the percentage of individuals with clinical VAD (ACC/SCN paper No.19).

Total

28

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Table 1 Vitamin A deficiency: prevalence trends in children (6-70) months since 1975 PROVINCE CLINICAL 1975 Western 0.9 Central 1 North Central 0.7 Southern Northern 0.6 Eastern 1 North western Uva 0.9 Sabaragamuwa 2 SRI LANKA 1.1 1.8 0.8 3.9 49.5 32.5 0.0 35.0 0.7 _ 0.3 _ 46.0 _ _ 1.8 0.5 1.3 56.8 41 0.5 21.8 1 23.3 1995 SUB CLINICAL 1975 1995

Sri Lanka has initiated the supplementation with high-dose Vitamin A capsules in the year 2000, but the reports are not available on capsule coverage. Though the clinical deficiency was low in North Central Province, the sub clinical deficiency was higher. The Sabaragamuwa Province has shown both clinical and sub clinical deficiency. All the Provinces have shown a severe sub clinical VAD. The estimated prevalence of clinical VAD in 1995 is 0.95% in South Asia and the sub clinical deficiency is around 10 – 20% (Asian Development Bank 1999). It is interesting to note that the sub clinical deficiency in Sri Lanka is higher than the estimates.

29

NIS/MRI

3.1.6. IODINE DEFICIENCY Iodine deficiency control is being tackled in the country through salt iodisation, which is supported by legislation. Three indicators were used to assess the magnitude of the problem and as the process indicators, i.e. goitre rates among school children, median urinary iodine concentration among school children and the percentage of households’ consumption of adequately iodised salt. 3.1.6.1. Goitre rates The rate of goitres in school children aged 8-14 years is a convenient way to assess the iodine status of a community. Figures 26 and 27 show the past and present distribution of goitre rates by districts. It shows the decline of goitre rates in some districts and the increase in some districts namely Anuradhapura and Polonnaruwa. But not a single district shows less than 5% of goitre rates, which is the indicator to the elimination of iodine deficiency. The major cause for this is that the iodine content varies very widely among manufacturers, wholesalers, and retailers and at household levels. Figure 26 and 27 Prevalence of goitre by districts (Source: Fernando et al. 1989 and MRI 2001)

3.1.6.2. Median urinary iodine concentration Figure 28 shows that the Badulla and Matara districts have mild iodine deficiency according to median urinary iodine concentration, which indicates the most recent iodine nutritional status.

30

NIS/MRI

Figure 28: Prevalence of median urinary iodine concentration by districts Figure 29: Percentage of households used the adequately iodised salt by district
(Source: MRI 2001)

3.1.6.3. Household consumption of adequately iodised salt The percentage of households that use the adequately iodised salt is only below 50% in Badulla and 5069% in Matara (Figure 29). This may be the cause of mild iodine deficiency in these districts. In the districts, which have shown more than the adequate level in urine the percentage of households, which use iodised salt, are less than 50% except in Polonnaruwa district. This may be due to high level of mineral content in drinking water.

31

NIS/MRI

3.2. Appropriate analysis of the causes of the problem by provinces or districts The results are presented only with the causes of protein energy malnutrition (PEM) of children less than 5 years. It includes the appropriate analysis of description of the causes of malnutrition. 3.2.1. CAUSES OF PROTEIN ENERGY MALNUTRITION OF CHILDREN UNDER 5 YEARS Conceptual framework of the causes of malnutrition was used to facilitate the assessment and analysis of the causes of malnutrition (Figure 1). In this framework, casual factors and their interactions are shown at three main societal levels-immediate, underlying and basic. 3.2.1.i. Immediate causes The immediate causes of malnutrition are the inadequate dietary intake and disease. 3.2.1.i.a. Dietary intake:



dietary energy consumption,

This was used as an indicator to assess the dietary intake of the population. National data on dietary energy consumption by the sector is presented in Figure 30. Estate sector showed the highest intake of energy but the activity levels are very high among them due to the nature of manual work involved. However, the energy level has not reached the Recommended Dietary Allowances (RDA) of active male. Rural sector has shown an improvement of energy intake from 1969-1997. Literature suggests that when there is an inadequate dietary intake, it is not only the intake of energy and protein, which is low, but also the intake of some micronutrients.

Figure 30 Tre nds in pe rcaput die tary e ne rgy consumption by se ctor, 1969-97
(source: Central Bank, 1998) 3500 3300 3100 2900 2700 2500 2300 2100 1900 1700 1500 1969/70 URBAN RURAL ESTATE RDA(sedentary male) RDA(active male) RDA (sedentary female) RDA (active female)

Kcal

1978/79 Year

1981/82

1996/97

32

NIS/MRI

3.2.1.i.b. Diseases: Diarrhoea and Acute Respiratory Infection (ARI) contribute significantly to the high prevalence of PEM. There is an important relationship between infections and dietary intake. Therefore the following indicators were assessed to determine the relationship.



infectious disease rates - Figure 31,
Figure 31 Tre nds in Hos pitalis ation of infe ctious dise as e s in Sri Lank a, 1975-2000 ( Source: Annual Health Bulletin,2000)

1000

Cases per 100,000 population

900 800 700 600 500 400 300 200 100 0 1975 1980 1985 1990 1995 2000

Intestinal infec dis Helminthiasis

Nutr. Defi.

The infectious disease rate was assessed by using the hospital data on national basis because the reliable district data was not available. The districts, which have major hospitals, have higher rates of cases because the data provided by the hospital indoor morbidity mortality register is not validated according to the residence. However, Figure 31 clearly showed that there is a decreasing trend in hospital admissions with infectious diseases and that admissions due to nutritional deficiencies and helminthiasis are negligible. 3.2.1.ii. Underlying causes Household food insecurity, inadequate caring practices and inadequate access to basic health services, together with an unhealthy environment, are the underlying causes of inadequate dietary intake and diseases and consequently of malnutrition. 3.2.1.ii.a. Household food insecurity This was assessed by per-capita food availability (measured in total energy) in the country as shown in Figure 32. Per capita food availability has not got changed much during last 20 years. But the availability of animal foods has increased a little during this period.

Year

33

NIS/MRI

Figure 32 Change in per-captia food availability (in total energy) in Sri Lanka, 1982-1999
(Source: Sri Lanka food balance sheet 1982-1999)
2500 2000 1500 1000 500

Vegetable Animal

Calories/day

0 1982 1984 1995 1997 1999

Year

Two other indicators were identified to analyse the household food insecurity, i.e., the percentage of poor household and average per capita calories consumption for poor households. The geographical distribution was also analysed (Figure 33 and 34). Figure 33 and 34 Percentage of poor households by district and average per capita calories consumption for poor households by district

(Source: Consumer Finance Survey 1999, statistical abstract, 2000) Note: Those households spending more than 50%, of the expenditure on food and adult equivalent food expenditure is less than Rs. 743 per adult per month (excluding non-food) are considered as poor households.

More than 40% of the population were categorised as poor households in Matale, Monaragala and Ratnapura districts. It is interesting to note that the per capita calorie intake of the poor in these districts

34

NIS/MRI

is between 1600-1699 except in Monaragala district. This calorie intake is not at all adequate for very active manual workers who live in these districts. It is interesting to note that in the Colombo district the per capita calorie intake is between 1500-1599 calories (the lowest intake reported in the country) in spite of only less than 10% of the population being considered poor. 3.2.1.ii.b. Adequate care for children and mother Caring practices constitute the most neglected determinant of young child malnutrition, but it is the least satisfactory condition at present. Caring practices can be divided into four major components: (United Nation 1997) Feeding practices, including breast-feeding and complementary feeding practices. Hygiene practices, including personal, food and household hygiene. Home based health care, including ORT, early detection of illness and health seeking behaviour. Psycological practices, including early childhood stimulation. The National data on exclusively breast-feeding pattern shows the proportion for infants in the age group of (5-11) months was 55% in 2000. Seventy-five percents of mothers have provided their infants below four months with only breast-feeding and 90% of children are breast-fed for more than one year. However, the district data varies a lot (DHS 2001). In Sri Lanka, 60% of children of 4-6 months aged were introduced complementary foods in 1994. But the data related to the quantity, quality and frequency are also equally important and the data are lacking. Very few localised studies were carried out about hygiene practices. Both households and personal hygiene are very important aspects of care. This may be one explanation of the big difference in malnutrition between districts. The indicator to assess the home-based care is use of Oral Rehydration Therapy (ORT) by mothers. This information is collected by the Public Health Midwife. The above information related to caring practices were not available by district it was decided to assess the situation by taking an indirect indicator as shown below.

35

NIS/MRI

I. Child and maternal mortality rates Figure 35 shows that the child and maternal mortality rates had declined since 1945. At present it is at a minimum level. Therefore the geographical distribution was assessed to detect the micro level problem.
Figure 35 Infant mortality (IM R), Ne onatal mortality rate (NM R) and M ate rnal mortality rate (M M R) in Sri Lanka,19452000
(Source:Registrar general department, Annual health bulletin 1999)

180 160 140

NMR IMR MMR

per live births

120 100 80 60 40 20 0

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

1997

Year

Figure 36 and 37 Infant Mortality Rate (IMR) per 1000 live births by district from 1988-1997
(Source: Registrar General's Data from Statistical Abstract 2000)

36

NIS/MRI

Figure 38 and 39 Maternal Mortality Rate (MMR) per 10,000 live births by district from 1988-1996
(Source: Registrar General's Data from statistical abstract 2000)

Figure 36, 37, 38 and 39 show the infant mortality rate and maternal mortality rate respectively. IMR is higher in Rathnapura, Nuwaraeliya, Kandy, Badulla, Anuradhapura, Mullativ and Kilinochchi than in other district. MMR is highest among the Ampara, Mullative and Kilinochchi districts, which are war torn areas. 3.2.1.ii.c. Access to basic health services and a healthy environment These are underlying determinants of young child malnutrition. Coverage of measles immunisation and percentage of births attended to by a trained health staff are two indicators of the access to basic health services. I. Access to basic health services In Sri Lanka the percentage of births attended to by a trained health staff is almost 99%. Figure 39 and 40 shows the coverage of measles immunisation in 1995-2000. The immunisation was initiated in 1985 and the coverage is above 95% in most of the districts. But Kandy district has a low coverage, which is below 85%. While Vavuniya district, which is an area ravaged by war has a level about 80-89%.

37

NIS/MRI

Figure 40 Measles immunisation coverage by districts from 1995-2000 Coverage of measles immunisation and percentage of births attended to by a trained health staff showed the sufficient level of basic health services in all the districts of Sri Lanka. However, these data do not show anything about the quality of services provided.

II. Healthy environment

– –

availability of clean water, availability of sanitary latrines Figure 41, 42, 43 and 44

Availability of safe drinking water and adequate sanitary latrines by districts from 1981-2000
(Source: Census of population and housing 1981 from Annual Health Bulletin 1994-2000)

38

NIS/MRI

The data on water and sanitation are shown in Figure 41, 42, 43 and 44. While access to water has improved significantly since 1981, access to sanitary facilities is still very low. 3.2.1.iii. Basic causes Education and information are crucial in determining how resources are used. 3.2.1.iii.a. Literacy rate Sri Lanka has a very high rate of literacy as shown in Figure 45. There is no significant difference between male and female literacy.
Figure 45 Literacy rate by sex in Sri Lanka from 1881-1996/7
(Source: Annual Health Bulletin 1999, North and East not included)

100 90 80 70 60

Male Female

%

50 40 30 20 10 0

1881

1891

1901

1911

1921

1946

1953

1963

1971

1981

1994

1996/97

Year

39

NIS/MRI

Educational attainment is shown in Figure 46. About 40% attained education up to primary level in Uva, North Central and Central provinces. About 30-35% have received an education up to secondary level except in Western Province. This is also an important determinant during the nutrition education.
Figure 46 Educational attainment by Provinces 1996/97
(Source: Central Bank of Sri Lanka 1996/97)

No schooling Primary Secondary Tertiary

45 40 35 30 25 20 15 10 5 0
rn ste We P NW e uth So rn P NC wa mu ga ra ba Sa a ntr Ce l a Uv

%

Provinces

3.2.1.iii.b. Maternal education Female literacy is now widely recognised to be an important determinant of the health of the Nation. Female literacy is lowest in the Uva Province and highest in the Western Province (Figure 48). Control of resources at household level is as important as their availability in the household. In households, where women control more resources, therefore the female education is an important determinant of child malnutrition.
Figure 48 Literacy rate by se x by Provinces 1996/97
(Source: Central Bank of Sri Lanka 1996/97) 100 95 90

Male Female

%
85 80 75
rn ste We P NW e uth So rn P NC S a wa ntr mu Ce ga ara ab Provinces l a Uv

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NIS/MRI

3.3. Resources available to combat the problem Resources are required to fulfil the necessary conditions of food, health and care. Both the availability and control of resources are important. Resources can be divided into human, economic and organisational resources. This section is not dealt due to limited logistics. The summary of findings is tabulated in the Table 3. Table3 Summary findings of the NIS Group Pre-school children Problem Low Birth Weight Findings It is still a public health problem in Sri Lanka. Highest prevalence was detected in NuwaraEliya, Badulla, Monaragala and Batticaloe district. High proportions of estate workers are residing in these districts. The data screening should be done at district level to get more accurate information. Stunting NuwaraEliya district still shows a high level of stunting. Kandy, Badulla and Monaragala district have moderate degree of stunting and rest of districts have low degree of stunting. Wasting Though national level of wasting has not got changed, the district level improvements are remarkable. At present, the more concentration should be focussed on the districts, which still maintain the very high levels of wasting, i.e., Kurunagala, Anuradhapura, Polonnaruwa, Kandy, Monaragala and Hambantota. Primary-school children Stunting Badulla district has moderate degree of stunting and it is the highest rate reported. All the other districts surveyed are having mild degree of stunting. This finding is comparative with the stunting rates among children under 5 years of age except in Monaragala district. Wasting Very high grade of wasting has found in Kurunagala, Monaragala and Hambantota districts. All the other districts, which were studied also having high degree of

41

NIS/MRI

wasting. Similar type of pattern is observed when compared with the wasting prevalence among children less than 5 years except in Anuradhapura district, which shows the shifting from very high prevalence to high prevalence from pre-school to school. Adolescents Thinness Hambantota district has shown a very high level of thinness. All the other districts studied were indicated high level, which is comparative with the pattern observed among primary school children except in Monaragala and Kurunagala districts, which shows the improvement from very high level to high level from primary school to adolescents. This finding indicates when the children close, at or passing the growth spurt that they had catches up the growth. Overweight The increasing pattern was observed among adolescents. Colombo district has a very high level that is shifted from medium to very high levels with primary schoolchildren. Even the Badulla and Polonnaruwa districts have increasing trends from low to high prevalence. This is the situation to be aware and alert with the decreasing trend of under nutrition in the country. Adults Diet related chronic degenerative diseases There is an upward trend of Diabetes Mellitus, Hypertension and Ischaemic Heart disease among hospital admissions and contrast to that the downward trends of helminthiasis and vitamin deficiencies and intestinal infections. Changing dietary patterns The oils, fats, sugar and meat availability has increased in contrast to the decreased trend of the availability of the pulses, nuts. Urban population consumes more animal food like meat, fish and milk than rural and estate population. Overweight and obesity The high prevalence of overweight among females than males. The prevalence of overweight is more among the

42

NIS/MRI

40-49 years age groups and then the reducing trend has observed. This is an alarming situation when compared with the increasing trend of non-communicable diseases. This is one of the issues to be addressed urgently. Underweight The prevalence of underweight is also high among adults especially in the rural population. There are no existing programmes to address this problem. Vitamin A deficiency Sri Lanka has initiated the supplementation with highdose Vitamin A capsules in year 2000, but the reports are not available on capsule coverage. Though the clinical deficiency is low in North Central Province, the sub clinical deficiency was higher. Sabaragamuwa Province has shown both clinical and sub clinical deficiency. All the Provinces had shown a severe sub clinical VAD. Iodine deficiency Sri Lanka has shown a tremendous improvement towards the elimination of iodine deficiency through the salt iodisation programme. Moderate degree of goitre prevalence has detected in the country. The major cause for this is that the iodine content varies very widely among manufacturers, wholesalers, and retailers and at household levels. Quality control and monitoring of salt iodine levels are the priority. To reduce the level of iodine in salt at household and production sites should be concerned. Causes of protein energy malnutrition of children under 5 years 1. Estate sector showed the highest intake of energy. However, the energy level has not reached the Recommended Dietary Allowances (RDA) of active male. 2. There is a decreasing trend in hospital admissions with infectious diseases and the admissions due to nutritional negligible. 3. Per capita food availability has not got changed much deficiencies and helminthiasis are

43

NIS/MRI

during last 20 years. But the availability of animal foods has increased a little during this period. 4. More than 40% of the population were categorised as poor households in Matale, Monaragala and Ratnapura districts. 5. Per capita calorie intake of the poor in these districts is between 1600-1699 except in Monaragala district. This calorie intake is not at all adequate for very active manual workers who live in these districts. 6. In the Colombo district the per capita calorie intake is between 1500-1599 calories (the lowest intake reported in the country) in spite of only less than 10% of the population being considered poor. 7. Data related to the quantity, quality and frequency of complementary feeding is lacking. 8. While access to water has improved significantly since 1981, access to sanitary facilities is still very low. 9. Female literacy is lowest in the Uva Province and highest in the Western Province.

44

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CHAPTER 4 Establishment of NIS and use of information
Mock and Mason stated in 1999, Nutrition information systems are an essential component of national investment programmes aimed at reducing the incidence and prevalence of malnutrition in Asia (Asian Development Bank 1999). The analysis presented in Chapter 3 uses the UNICEF conceptual framework to develop the NIS across Provinces and districts and it explores relationships, especially between immediate, underlying and basic causes and malnutrition. The last 10-12 years data was used to develop this information system. This clearly shows that routinely collected data can be used to gather information for following indicators:  Infants and preschool children:  Low Birth Weight  Underweight  School children  Stunting (year 1, 4)  Wasting (year 1,4)  Overweight (year 1,4)  Adolescence  Thinness (year 7)  Overweight (year 7)    Pregnant women  Underweight Adults  Diet related chronic degenerative diseases Causes of malnutrition under 5 years  Inadequate maternal and child care  Access to basic health services  Healthy environment Sri Lanka has routine on-going data collection by the Public Health Midwives (PHM) and Public Health Inspectors (PHI) and sends to the Medical Officer of Health (MOH) monthly or quarterly to compile. Data related to the above indicators, which were used to build up the NIS could be collected from PHM or PHI level. Some of the data are already collecting to use for Maternal and Child Health activities, i.e., Growth

45

NIS/MRI

monitoring data (number of under weight children), number of low birth weight children, number of infant deaths, number of neonatal deaths, number of maternal deaths, breast feeding, measles immunisation coverage, percentages of births attended by a trained health staff, safe drinking water, adequate sanitary facilities etc. By building the NIS from these data will enhance the quality and use of routine data by the data collectors themselves.  In general, the approaches should be explored to strengthen these data sources wherever possible to join into the system. Attempt should be made to obtain comparable data from other surveys and studies e.g. DHS In Sri Lanka Demographic and Health Survey tend to collect detailed information on population and health, socioeconomic status and household food access etc. but it was designed to collect the information on Ecological Zone basis. Therefore this information is not possible to use by Provincial or district's policy makers. In addition to this survey income and expenditure survey is going on every 10 yearly by Central Bank of Sri Lanka. Medical Research Institute has undertaken the nationally representative surveys on Iodine, Anaemia and Vitamin A. National sample surveys are necessary to build up the Project's nutrition information strategy, preferably within five-year intervals. Therefore NIS will help the comparability across districts and Provinces quarterly or yearly.  Changing of methodological issues in DHS survey to collect data by Provinces. This can validate with routinely collected information to facilitate accurate reporting. It is a big assert to the decision makers. Policymaking requires information that addresses causality, and that demonstrates the consequences of various policy options to policymakers (Asian Development Bank 1999). Prevalence and causes of malnutrition in districts varied. It is important to prioritise the causes accordingly. Then the interventions varied from district to district. NIS will directly support to identify the priorities on district basis. Then it is easy for policy makers to deviate from the common policies relevant to nutrition like food subsidies and poverty alleviation programme. The following issues were highlighted in the analysis which can be used during the policy decisions:

46

NIS/MRI

 The universal availability of drinking water and sanitary toilets to all households should be ensured because it was found lacking in most districts. It will help to reduce of malnutrition in children linked with water-born infections.  Female education should be upgraded in Uva and Central province to facilitate the nutrition education and essential childcare support.  Since per capita calorie consumption is very low in poor households of Colombo district, targeting of nutrition interventions should be carried out to reach children from those households.  Associated problems like food security; caring practice data should be linked to the routine information collection by adding the identified indicators to the system.  Awareness should be created among urban sector people the high consumption of meat and sugar may relate to cardiovascular disease morbidity.  Screening of adult population after 40 years of aged is important due to increase overweight prevalence from 35 years and obesity since 55 years, this may be linked to well women clinic with the concept of upgrading family health. This may be related to rising level of noncommunicable diseases. The absence of data for evaluation of nutrition and community based programmes, is a major constraint to the design of Provincial or district programmes. This is true in the area of under nutrition reduction, low birth weight reduction, anaemia and care of young children. NIS will address this information gap, which is a priority. An important information tool, which is used in this NIS, is Geographical Information system. In Chapter 3, most of the information is mapped out by districts to detect the problem and determinants. Same system can be extended to MOH and PHM areas because the maps and geographical boundaries are already available. It can be done manually or if the resources are available by using the computer. Programme planners, policy makers and Funding agents can use the mapping and analytical products regularly for programme design and implementation.  Establishment of the NIS and the regular mapping of the prevalence of malnutrition at PHM, PHI, MOH, DPDHS and PDHS level should be done. Following indicators can be used at each level. PHM level:  Infants and preschool children:  Low Birth Weight

47

NIS/MRI

 Underweight   Pregnant women  Underweight Causes of malnutrition under 5 years  Inadequate maternal and child care  Access to basic health services PHI level:  School children  Stunting (year 1, 4)  Wasting (year 1,4)  Overweight (year 1,4)  Adolescence  Thinness (year 7)  Overweight (year 7)  Causes of malnutrition under 5 years  Healthy environment MOH level:  Infants and preschool children:  Low Birth Weight  Underweight  School children  Stunting (year 1, 4)  Wasting (year 1,4)  Overweight (year 1,4)  Adolescence  Thinness (year 7)  Overweight (year 7)   Pregnant women  Underweight Causes of malnutrition under 5 years  Inadequate maternal and child care  Access to basic health services  Healthy environment

48

NIS/MRI

DPDHS level:  Infants and preschool children:  Low Birth Weight  Underweight  School children  Stunting (year 1, 4)  Wasting (year 1,4)  Overweight (year 1,4)  Adolescence  Thinness (year 7)  Overweight (year 7)    Pregnant women  Underweight Adults  Diet related chronic degenerative diseases Causes of malnutrition under 5 years  Inadequate maternal and child care  Access to basic health services  Healthy environment Maps should be up-dated periodically (quarterly, annually) to identify the areas representing pockets of severely malnutrition in children less than 5 years and school children and nutrition programmes should be targeted on such areas. To complete the process of Triple A cycle, dissemination of information generated from NIS to policy makers by a Newsletter or bulletin quarterly is needed. Then information can be use to evaluation of programmes. The evaluations of impact of nutrition interventions are required to identify the gaps. However, evaluation research is the weakest element of nutrition information strategies in Asia and elsewhere. It is unwise to assume that well-established interventions are always contributing to reducing deficiency, especially as circumstances change, and light of the growing knowledge of interactions among nutritional deficiencies and the complexity of human biochemistry (Asian Development Bank 1999). Evaluation designs can be developed through NIS by MOH, District, Provincial and National level yearly.

49

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CHAPTER 5
REFERENCES 1. Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;2000. 2. Ministry of Health Highways and Social Services, Project Proposal for the Nutrition componentWorld Bank assisted Sri Lanka health services development project;1995 3. UNICEF. Strategy for improving nutrition of children and women in developing countries, United Nations Children's Fund, New York, USA:1990. 4. World Health Organisation, Physical status: The use and interpretation of anthropometry - Report of a WHO Expert Committee, WHO Technical Report series 854, Geneva;1995. 5. Asian Development Bank, Asian Development Review- Studies of Asian and Pacific Economic Issues,17(1,2);1999. 6. World Health Organisation, Global database for malnutrition among children under 5 years, 2002. 7. Sri Lanka Demographic and Health Survey, Department of Census and Statistics;2001 8. Ministry of Policy Planning and Implementation, Nutritional status survey report, Nutrition and Janasaviya Division;1980/2 9. Ministry of Policy planning 1988/9 10. Medical Research Institute, Vitamin A deficiency status of children Sri Lanka 1995/6, A survey report, Ministry of Health and Indigenous Medicine;1998. 11. Medical Research Institute, Anaemia status report in Sri Lanka, unpublished;2002 12. Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;1991 13. Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;1992 14. Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;1993 15. Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;1999. 16. ACC/SCN,. ACC/SCN Symposium Report. UN Sub-committee on Nutrition. Nutrition policy paper #19; 2001. 17. Prior IA, Davidson F, Salmond CE, Czochanska Z. Cholesterol coconut and diet in Polynesian atolls a natural experiment tye Pukapuka and Tohaleau island studies. American Journal of Clinical Nutrition; 1981;32:1552-1561. 18. Mendis S. Cardiovascular researches in Sri Lanka. Review and Bibliography (1905-1998). Ministry of Health, Colombo, Sri Lanka; 1998. 19. World Health Organisation. Non communicable diseases prevention and management. South-East Asia Region; 2001.

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20. Department of census and statistics. Statistical Abstract of the Democratic Socialist Republic of Sri Lanka, Sri Lanka Food balance sheet 1982-1984, Ministry of Plan implementation; 1985. 21. Department of census and statistics. Statistical Abstract of the Democratic Socialist Republic of Sri Lanka, Food balance sheet, Ministry of Finance and planning; 1997. 22. Department of census and statistics. Statistical Abstract. Ministry of Finance and planning Sri Lanka; 2000. 23. ACC/SCN, Nutrition and Poverty. ACC/SCN Symposium Report. UN Sub-committee on Nutrition. Nutrition policy paper #16; November: 1997. 24. Central Bank of Sri Lanka, Socio-economic and Finances survey-1996/7;1998. 25. Fernando MA, Balasuriya S, Herath KB, Katugampola S, Endemic Goitre in Sri Lanka, Asia Pacific Journal of Public Health,3(1);1989 26. Medical Research Institute, Iodine deficiency status in Sri Lanka 2000/1, Survey Report, Ministry of Health;2001.

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ANNEX-1
MEMBERS OF THE CORE-GROUP
1. 2. 3. 4. 5. 6. 7. 8. 9. Dr. Aberra Bekale Mrs. Soma De Silva Prof. D.N. Fernando Dr. H.M. Fernando Dr. S.A.P. Gnanissara Dr. C.D. Gunaratne Dr. V. Karunaratna Dr. Nynt Nynt Yi Dr. S. Manikkarajha - Head, Nutrition and Estate programme, UNICEF - Ex-Head, Evaluation and statistics unit, UNICEF - Professor of Community Medicine, Faculty of Medicine, Colombo. - Deputy Director General of Public Health Services, Department of health - Ex-Deputy Director General (ET&R), Department of health - Director Nutrition, Department of health - Director, Family Health Bureau - Ex-Head, Nutrition and Estate programme - Ex-Director, Estate and Urban health, Department of health - Head, Nutrition Department, Medical Research Institute - Associate Professor of Comm. Medicine, Faculty of Medicine, Colombo. - Director, Ministry of Plan Implementation - Ex-Director, Family Health Bureau - Ex-Director, Family Health Bureau - Emirates Professor of Biochemistry

10. Dr. C. Piyasena 11. Prof. L. Rajapaksa 12. Mr. N. Sumanaratne 13. Dr. Vidyasagara 14. Dr. K.P. Wickramasuriya 15. Prof. T.W. Wikramanayake

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ANNEX-2 Study Team
Dr. Renuka Jayatissa Dr. C.L. Piyasena Dr. A.M.A.S.B. Mahamithawa Dr. I. Warnakulasuriya Mr. J.M.Ranbanda Mr. K.D. Chandrathilaka Mr. A.P. Seneviratne Mr. H.K.T. Wijesiri Mr. H.N.P. Caldera Mr. P.V.N. Ravindra Mr. E.G.S. Kulasingha Mr. M.A.M.P.K. Marasingha Mr. W.A.P.I. Pieris Mr. J.S.Dean Laboratory team: Mrs. T. Amarasena Mrs. K.S.N. Jayaratne Mrs. B.Y. Gamage Miss. H. Kulathunga Mr. P. Gamage Mrs. W. Polpitiya Mrs. A.G. Sriyani - Research Officer - Medical Laboratory Technologists - Medical Laboratory Technologists - Medical Laboratory Technologists - Laboratory Orderly - Laboratory Orderly - Labourer - Consultant Nutritionist (Principal Investigator) - Head - Medical officer - Medical officer - Nutrition Assistant - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Secretary

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