Nutritional Surveillance

NUTRITIONAL
SURVEILLANCE
Dr. Osahon Otaigbe
Department of Community Medicine, ISTH Irrua 18th March 2020

OUTLINE
• List of Abbreviations
• Introduction
• Purpose of Nutritional Surveillance
• History of Nutritional Surveillance
• Process of Nutritional Surveillance
• Challenges of Nutritional Surveillance Systems
• Establishing a Nutritional Surveillance System
• Examples of Nutritional Surveillance in Nigeria
• Conclusion
• References
2

LIST OF ABBREVIATIONS…1
• BMGF – Bill and Melinda Gates Foundation
• DHS – Demographic and Health Survey
• FAO – Food and Agriculture Organization
• FMOH – Federal Ministry of Health
• MICS – Multiple Indicator Cluster Survey
• MUAC – Mid Upper Arm Circumference
Nutritional Surveillance - Dr. Otaigbe 18/3/2020 3

• NACA – National Agency for the Control of AIDS
• NDHS – Nigeria Demographic and Health Survey
• NPHCDA – National Primary Health Care
Development Agency
• SOML – Saving One Million Lives
• UNFPA – United Nations Population Fund
• UNICEF – United Nations Children’s Fund

• USAID – United States Agency for
International Development
• WHO – World Health Organization

INTRODUCTION…1
• Nutritional surveillance means to watch
over nutrition in order to make decisions
that lead to improvements in nutrition in
populations (Mason and Mitchell 1983)
• It involves the regular and systematic
collection of data on nutritional outcomes
and exposures.
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Nutritional Surveillance - Dr. Otaigbe 6

• The regular and timely collection, analysis
and reporting of data on nutrition risk
factors, nutritional status and nutrition-
related diseases in the population
INTRODUCTION…2
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PURPOSE OF NUTRITIONAL
SURVEILLANCE…1
• To monitor the nutrition situation
• To identify factors associated with
malnutrition
• To inform nutrition policies and programmes
• To track progress towards achieving nutrition
goals
• To serve as an early warning of increased
nutritional risk
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• To assess the delivery and coverage of
services
• To evaluate programmes and
interventions
• To detect the impact of change in policies
PURPOSE OF NUTRITIONAL
SURVEILLANCE…2
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HISTORY OF NUTRITIONAL
SURVEILLANCE…1
• First World Food Conference in 1974,
FAO, WHO and UNICEF were invited to
establish a global nutrition surveillance
system
• This led to national surveillance systems
being set up – about 20 countries by the
1980s
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• Early nutrition surveillance systems were
primarily based on growth monitoring
data from clinics plus infrequent surveys.
• A few school census systems existed
mainly in Central America
SURVEILLANCE…2
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• Today, there is substantial political
momentum to reduce the numbers of
children affected by undernutrition as
demonstrated by political and financial
commitments by national governments
and international organizations
SURVEILLANCE…3
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THE PROCESS OF NUTRITION
SURVEILLANCE
1. Collection
•Creates data
2. Collation
•Creates
organized data
3. Analysis and
interpretation
•Creates
information
4. Dissemination
& communication
•Leads to
knowledge
Decision making
and action
•Leads to
improvement in
nutrition
situation
13

Surveillance is a continuous process
ANALYSIS
of the causes of the
problem
ASSESSMENT
of the nutritional
situation in the target
population
The Analysis stage
aims to analyze the
causes of malnutrition
as represented in
various conceptual
frameworks such as
UNICEF
The Assessment stage
aims to define the
nutritional problem in
terms of magnitude and
distribution
ACTION
based on the
analysis and
available resources
14

DATA COLLECTION
• In nutritional surveillance, information
should be collected both on the
nutritional status of the population and
on the underlying causes of
malnutrition
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MAJOR DETERMINANTS OF
NUTRITIONAL STATUS…1
16

1. Nutritional status depends on the dietary
intake of food and nutrients as well as
disease.
2. The dietary intake or food consumption
of a family or a person depends on the
food available to the family and on the
nutrition awareness in the family.
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3. Food availability depends:
(a)on the relation between food prices and
earnings in a market economy;
(b)on the food harvests in subsistence
households; and
(c)on both the price– wage relationship and on
production in mixed market and subsistence
households (the exact relationships between
these factors and food availability in a mixed
household economy are not usually known and
are difficult to determine).
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4. The relation between food prices and
earnings is largely influenced by imports
or food aid.
5. Local food production is influenced by
many interrelated factors, both inside
and outside the country (e.g. the
weather).
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6. Food utilization depends on the
physiological status of the human body
which, in turn, is influenced by the
environment, accessibility to safe water,
and the morbidity status which itself
results from inadequacies in the
environment and water and sanitation
situations.
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INDICATORS TO BE MONITORED…1
• Anthropometric and biochemical
indicators are used to assess nutritional
status of the population
• These indicators aim to answer the
following questions:
–Who suffers from malnutrition? (children,
elderly, mothers)
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–What is the type of malnutrition? (wasting,
stunting, iodine deficiency)
–When? (recent or chronic problem)
–Where? Which areas are most affected?
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• There are 3 primary anthropometric
indices for children under five years of age
–Wasting (using weight-for-age and MUAC)
–Underweight (using weight-for-age)
–Stunting (using height-for-age)
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• Food security, health and care practice
indicators are used to analyze the causes
of the nutritional problem
–Why are people malnourished or at risk of
malnutrition?
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METHODS OF DATA COLLECTION…1
• Large-scale national surveys
• Repeated small-scale surveys
• Clinic-based monitoring
• Sentinel site surveillance
• School census data
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• Rapid nutrition assessments
• Rapid screening based on MUAC
measurement
• Selective feeding programmes or services
statistics monitoring
METHODS OF DATA COLLECTION…2
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LARGE-SCALE NATIONAL SURVEYS…1
• Examples include Demographic and Health
Surveys (DHS), Multiple Indicator Cluster
Surveys (MICS)
Advantages
• They provide valuable data to assess trends in
nutrition nationally and globally.
• Long-term trends can be observed.
• Standardized methodology
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Disadvantages
• Need to train and supervise large numbers of
surveyors for quality control
• High cost
• Long period between data collection and
release of findings
• Acute malnutrition could be missed because
of long period between surveys
LARGE-SCALE NATIONAL SURVEYS…2
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REPEATED SMALL-SCALE SURVEYS…1
• They are the most common method used in
emergencies.
• To be comparable, they should be conducted
in the same geographical area and at the
same time/season of the year.
• Repeating the surveys make them useful in
surveillance as against a single ad-hoc small-
scale survey
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Limitations
• Require technical expertise
• High cost
REPEATED SMALL-SCALE SURVEYS…2
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CLINIC-BASED MONITORING
• A component of health information system
• Can be applied both in emergency and non-
emergency situations
Limitations
• Population attending clinics may not be
representative
• Captures only younger children
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SENTINEL SITE SURVEILLANCE…1
• Monitoring of a set of indicators in selected
communities or service-delivery sites
• Ranges from technically sophisticated large-
scale to simple community-based monitoring
of several key indicators
• Aims to produce trends in the nutrition
situation in identified vulnerable areas in
order to provide early warning of
deterioration
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Limitations
• Problems with analysis of data and
representativeness
SENTINEL SITE SURVEILLANCE…2
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SCHOOL CENSUS DATA…1
• To identify high-risk populations with
poor health, malnutrition and low
socioeconomic status
• Focuses on stunting and can provide large
coverage
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SCHOOL CENSUS DATA…2
Limitations
• Not useful in emergency situations
• Representativeness is determined by
school attendance
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RAPID NUTRITION
ASSESSMENTS/RAPID SCREENINGS…1
• They are conducted to obtain a quick
snapshot of the nutrition situation.
• Important source of information
especially at the onset of an emergency to
determine magnitude and severity of a
crisis
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Limitation
• Information may not always be
representative
RAPID NUTRITION
ASSESSMENTS/RAPID SCREENINGS…2
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PROGRAMME/SERVICE STATISTICS
• Indicators such as admissions, cure,
defaulting and case-fatality rates provide a
measure of:
– programme quality
– trends in acute malnutrition
– the most vulnerable groups
– seasonal trends
– Underlying causes of malnutrition such as
morbidity patterns
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ANALYSIS OF DATA
• Variety of tools
• Quality control, major challenges
– Accurate estimation of age
– Height/length measurement
– Weight measurement
• How to address them
– Training and ongoing supervision
– Quality checks with specialized softwares
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PRESENTATION OF DATA
• Compare current data with previous and
establish trends: numbers in isolation mean very
little.
• Seasonal interpretation is also critical
• Consider underlying causes and assess
predictable changes in the nutrition situation:
– risk factors likely to result in further deterioration
– mitigating factors leading to improvement
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INTERPRETATION OF DATA…1
• To properly understand and interpret nutritional data,
the following should be considered:
– The actual prevalence rates of acute malnutrition in relation
to thresholds and decision making frameworks
– Trends over time and seasonality (reviewing expected
seasonal changes in nutritional status),
– The underlying causes of acute malnutrition
– The relationship between malnutrition and mortality
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DISSEMINATION OF DATA
• There must be timely dissemination of
information to aid appropriate responses
especially in a crisis situation.
• Can be done through national nutrition
coordination units or clusters
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CHALLENGES OF A NUTRITIONAL
SURVEILLANCE SYSTEM…1
• Sustainability and continued effectiveness
of the system
–Waning donor interest
–Change in funding priorities
–No crisis situation for a long period
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• Institutionalization – Reliance on
information sources that cut across several
government ministries can pose problems
– Where the system should be located
– How it links with existing systems
– Who ultimately makes the decisions about the
analysis of the information
– Who determines the appropriate response
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• Linking information to action
–Lack of confidence in the data
–Political reasons for failing to act on
surveillance information
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• Be clear on the objectives and what the
information will be used for (Consider the
availability of resources, staff capacity,
sustainability, environmental factors and
response capacity).
• Review and map existing nutrition
information sources to prevent duplication
and where possible, ensure linkage or
integration with existing information
systems.
ESTABLISHING A NUTRITION

• Define a minimum set of core indicators
that refer both to nutritional status and
provide an understanding of the
underlying causes of malnutrition.
• Design the system based on the most
appropriate methods. Several methods
may be appropriate in some contexts.

• Ensure adequate training and supervision
of data collection (include simple quality
checks to assure reliability of data).
• Consider contextual issues when
interpreting data: seasonality, population
movement, morbidity patterns and
historical trends.

• Ensure information is presented in a
timely and accessible manner to decision
makers and to the community.
• Establish triggers to determine when
more detailed nutrition assessments are
necessary.

• Consider how the information from the
surveillance system will link to action or
response.
• For longer term systems in emergency
prone areas, consider sustainability issues
from the outset.

EXAMPLES OF NUTRITIONAL
SURVEILLANCE IN NIGERIA
• MICS: 1995, 1999, 2007, 2011, 2016-17, 2020
(survey design)
• NDHS: 1986 (Ondo State), 1990, 1999, 2003,
2008, 2013, 2018
• Nutrition and food security surveillance:
North East Nigeria 2016
• National Nutrition and Health Survey: 2014,
2015, 2018
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MICS5 2016-17…1
• Carried out in 2016/2017 by the National
Bureau of Statistics in collaboration with
NPHCDA and NACA
• Technical support provided by UNICEF
• Financial support provided by WHO, World
Bank, SOML, BMGF, UNFPA, USAID and
UNICEF
(NBS and UNICEF, 2017)
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MICS5 2016-17…2
• Underweight prevalence in under 5
– Moderate and severe 31.5%
– Severe 11.5%
• Stunting prevalence in under 5
– Severe 22.8%
• Wasting prevalence in under 5
– Severe 2.9%
(NBS and UNICEF, 2017)
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NDHS 2018…1
• Implemented by the National Population
Commission in collaboration with the National
Malaria Elimination Programme of FMOH
• Technical support provided by ICF Maryland
through The DHS Program, a USAID-funded
project
• Financial support provided by USAID, Global
Fund, BMGF, UNFPA and WHO
(NPC and ICF, 2019)
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• Stunting prevalence in children 6 – 59
months 37%
• Wasting prevalence in children 6 – 59
months 7%
• Underweight prevalence in children 6 –
59 months 22%
(NPC and ICF, 2019)
NDHS 2018…2
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CONCLUSION
• Nutritional surveillance is essential to
monitor the nutrition situation in an area
and consequently decide on the best
course of action.

REFERENCES
• Mason JB and Mitchell JT, 1983. Nutritional
Surveillance. Bulletin of the World Health
Organization. 61(5):745-755.
• National Bureau of Statistics (NBS) and United
Nations Children’s Fund (UNICEF), 2017. Multiple
Indicator Cluster Survey 2016-17, Survey Findings
Report. Abuja, Nigeria: National Bureau of Statistics
and United Nations Children’s Fund.
• National Population Commission (NPC) and ICF,
2019. Nigeria Demographic and Health Survey 2018.
Abuja, Nigeria, and Rockville, Maryland, USA: NPC
and ICF.

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