1. Candidate indicators for measuring
progress at improving nutrition
Kathryn G. Dewey, PhD
Program in Community and International Nutrition
University of California, Davis
February 20, 2013

2. Anthropometric indicators (children)
• Stunting: HAZ < -2
– Reflects long-term linear growth, both prenatal and postnatal
– Moderately sensitive to nutrition interventions
– % stunted increases with age until ~24 mo, so indicator should be
measured on children 24+ mo (or age-adjusted, if includes 0-24 mo?)
• Wasting: WHZ < -2
– Reflects acute undernutrition
– Sensitive (in short-term) to nutrition interventions, but recidivism is
common
• Underweight: WAZ < -2
– Reflects combination of stunting and wasting, so is not as informative
– Rates decrease as overweight becomes more common, even if
stunting not reduced
• Overweight: WHZ > +2
– Good indicator of rising rates of child obesity

3.  Stunting is a non-specific indicator of nutritional
status and overall health, including:
- Quantity and quality of dietary intake (mother & child)
- Pre- and post-natal exposure to infections
- Environmental insults (e.g. mycotoxins, household air
pollution)
- Caregiving
 Stunting is linked to numerous adverse
outcomes:
• Increased child mortality
• Delayed development and less schooling
• Lower wages in adulthood
• Increased obstetrical risks (women)

4. How strong is the link between stunting
and child development/schooling?
• Attained schooling +0.5 y per 1 Z difference in HAZ at 2 y of age
in Brazil, Guatemala, India, Philippines (Victora et al. 2008)
• Higher cognitive scores at 5 years among Vietnamese children
who were taller at 1 y (+0.20-0.25 SD per 1 Z difference in HAZ)
(Young Lives Project 2009)
• Jamaican children stunted at 9-24 mo had cognitive deficits that
persisted at 17-18 y (Walker et al. 2005)
• Difference of 4 points in MDI at 18 mo between stunted vs. non-
stunted children in Tanzania (McDonald et al. 2013)
 Heterogeneity in the strength of the association with stunting
 Timing of stunting may play a role (e.g. pre- vs. postnatal)

5. Dietary candidate indicators
• Children under two: IYCF
indicators
• Adults
– Household food insecurity
– Measures of consumption
(energy intake?)
– Dietary diversity among
women of reproductive
age

6. Recommended core IYCF indicators
• Breastfeeding: a) Early initiation of breastfeeding; b) Exclusive breastfeeding
under 6 months; c) Continued breastfeeding at 1 year
• Introduction of solid, semi-solid or soft foods
• Minimum dietary diversity: Proportion of children 6-23 mo who
receive foods from 4 or more food groups (out of 7):
a) grains, roots, tubers, b) legumes, nuts, c) dairy, d) flesh foods, e) eggs, f)
vitamin A-rich fruits & vegs, g) other fruits & vegs
• Minimum meal frequency: Proportion of breastfed and non-breastfed
children 6-23 mo who receive solid, semi-solid, or soft foods (including milk
feeds for non-breastfed children) the minimum number of times or more
(BF: 2 times at 6-8 mo, 3 times at 9-23 mo; non-BF: 4 times 6-23 mo)
• Minimum acceptable diet: Proportion of children 6-23 mo who
receive a minimum acceptable diet
– Breastfed children who had at least minimum dietary diversity and
minimum meal frequency
– Non-breastfed children who received at least 2 milk feedings and had
minimum dietary diversity and minimum meal frequency
• Consumption of iron-rich or iron-fortified foods

7. Median prevalence values of IYCF indicators for 46
countries (data range from 2002 to 2008)
Lutter C K et al. Pediatrics 2011;128:e1418-e1427
©2011 by American Academy of Pediatrics

8. Women’s dietary diversity & micronutrient
adequacy
(Arimond et al., Women’s Dietary Diversity Project, J Nutr. 2010)
“MPA” is probability of adequacy averages across 11 micronutrients

9. Dietary diversity as an indicator?
• Reflects dietary quality
• All food-based national dietary guidelines include this
dimension, usually via recommended food groups for
daily consumption
• DD indicators are robust: Across all studies and all DD
indicators, there are moderate to strong associations
with nutrient density and/or nutrient intakes
• However, DD indicators are imperfect: Indicator
performance (sensitivity, specificity, and best cut-offs)
vary by context and all indicators result in some
misclassification
• For children 6-23 mo, “minimum acceptable diet” may
be a better indicator because it can be used for
comparisons across time and between populations with
different rates of continued breastfeeding.

10. Summary - Anthropometric
• Consider stunting as key indicator rather than
underweight?
• Pros: better indicator of conditions that support
health and development; if weight is measured
can also track overweight
• Con: requires measuring height – technical &
resource challenges
• Also include adult & child overweight as
indicators?

11. Summary - Dietary
• Children (6-24 mo): consider minimum acceptable diet as key
indicator?
– Pros: raises attention to IYCF, dietary quality; lots of room for
improvement
– Cons: composite indicator requires several survey questions;
validation results better for dietary diversity than for meal
frequency
• Adults: consider two indicators?
– Household food insecurity
• Pros: marker of access to food; sensitive to economic
trends
• Cons: requires several survey questions; are cross-
population comparisons valid?
– Dietary diversity among women of reproductive age
• Pros: reflective of dietary quality; validation data available
• Cons: sensitivity, specificity and best cut-off values vary
across populations