National Nutrition Survey 2018 PDF

NATIONAL NUTRITION SURVEY 2018 - KFR 1 Permission is required to reproduce any part of this publication. Please contact UNICEF Pakistan, Nutrition Section All Rights Reserved: UNICEF Pakistan Photographs: UNICEF Pakistan Designed by Hu...

NATIONAL NUTRITION SURVEY 2018 - KFR 1 Permission is required to reproduce any part of this publication. Please contact UNICEF Pakistan, Nutrition Section All Rights Reserved: UNICEF Pakistan Photographs: UNICEF Pakistan Designed by Human Design Studios 2 NATIONAL NUTRITION SURVEY 2018 - KFR Introduction The 2018 Pakistan National Nutrition Survey (NNS 2018), the largest national nutrition survey, in Pakistan. It is designed to provide to policymakers, programme managers and academicians a unique set of nutrition-related data including environmental, anthropometric and biochemical indicators. The study group included children, women of reproductive age (WRA) and adolescent boys and girls. NNS 2018 is the fifth national nutrition survey since 1965, but the first to yield district-representative data and to include adolescents and a component on water. NNS 2018 employed a cross-sectional survey design at the household level. It used a mixed-method data collection methodology with both quantitative and qualitative approaches. The sample design provides district level estimation at the national level for urban and rural localities and by gender, for the four provinces (Punjab, Sindh, Balochistan and Khyber Pakhtunkhwa, KP); and for the regions (Azad Jammu and Kashmir, AJK, and Gilgit-Baltistan, GB), KP-NMD and Islamabad Capital Territory (ICT). A national, province and district representative sample of 76,742 children (aged 0–59 months), 145,847 adolescents (10–19 years) and 145,324 WRA (15–45 years) was selected from 115,600 households.  Household Sampled Adolescent Households Women (15-49 years) Children under 5 (10-19 years) Household Women's Mothers/ Under-5's Sampled Occupied Interviewed response Eligible Interviewed response Eligible Eligible caretakers response rate rate rate interviewed Total 110146 105704 100304 94.9 155614 123092 79.1 64829 81324 68493 84.2 National Urban 33328 31908 29858 93.6 47155 37367 79.2 18314 22999 19641 85.4 Rural 76818 73796 70446 95.5 108459 85725 79.0 46515 58325 48852 83.8 Total 40452 38825 37086 95.5 55491 44409 80.0 20575 28139 24281 86.3 Punjab Urban 13312 12712 12016 94.5 18515 14644 79.1 6592 8893 7565 85.1 Rural 27140 26113 25070 96.0 36976 29765 80.5 13983 19246 16716 86.9 Total 18768 18149 17156 94.5 25895 20977 81.0 11664 14802 13082 88.4 Sindh Urban 10027 9702 9003 92.8 14068 11241 79.9 5823 7033 6233 88.6 Rural 8741 8447 8153 96.5 11827 9736 82.3 5841 7769 6849 88.2 Total 13710 13246 12222 92.3 20166 16110 79.9 9144 9736 8232 84.6 KP Urban 2803 2722 2464 90.5 4189 3316 79.2 1699 1952 1640 84.0 Rural 10907 10524 9758 92.7 15977 12794 80.1 7445 7784 6592 84.7 Total 18145 17230 16315 94.7 24874 20302 81.6 10483 14165 11879 83.9 Balochistan Urban 4011 3751 3495 93.2 5699 4625 81.2 2310 2938 2431 82.7 Rural 14134 13479 12820 95.1 19175 15677 81.8 8173 11227 9448 84.2 Total 1356 1304 1205 92.4 1792 1473 82.2 657 965 826 85.6 ICT Urban 659 632 582 92.1 817 654 80.0 281 482 405 84.0 Rural 697 672 623 92.7 975 819 84.0 376 483 421 87.2 Total 3595 3559 3355 94.3 5229 3475 66.5 2319 2463 1707 69.3 KP-TD Urban 199 197 188 95.4 324 201 62.0 112 114 72 63.2 Rural 3396 3362 3167 94.2 4905 3274 66.7 2207 2349 1635 69.6 Total 8449 7910 7579 95.8 12039 9229 76.7 4750 5634 4614 81.9 AJK Urban 1579 1484 1417 95.5 2246 1786 79.5 796 979 847 86.5 Rural 6870 6426 6162 95.9 9793 7443 76.0 3954 4655 3767 80.9 Total 5671 5481 5386 98.3 10128 7117 70.3 5237 5420 3872 71.4 GB Urban 738 708 693 97.9 1297 900 69.4 701 608 448 73.7 Rural 4933 4773 4693 98.3 8831 6217 70.4 4536 4812 3424 71.2 4 NATIONAL NUTRITION SURVEY 2018 - KFR For the biochemical assessment, 31,828 blood samples for WRA and 31,828 samples for children were planned to analyse. For water quality a sample size of 31,828 was estimated based on the prevalence of coliform and E. coli contamination of water. Planned Survey Sample Blood Samples Urine Samples Province/ Water PSUs HHs Region Samples WRA Children WRA Children Balochistan 794 15,880 7,297 7,297 745 745 7,297 KP 807 16,140 5,096 5,096 807 807 5,096 KP-NMD 377 7,540 2,070 2,070 377 377 2,070 Punjab 2,051 41,020 7,704 7,704 2,051 2,051 7,704 Sindh 945 18,900 5,656 5,656 945 945 5,656 ICT 68 1,360 340 340 68 68 340 GB 328 6,560 2,640 2,640 190 190 2,640 AJK 410 8,200 1,025 1,025 597 597 1,025 Grand Total 5,780 115,600 31,828 31,828 5,780 5,780 31,828 CHILDREN UNDER FIVE YEARS OF AGE A total of 68,493 mothers/caretakers of children under five were interviewed. Of these, 24,209 children under two years were assessed for infant and young child feeding (IYCF) practices. Of these children, 50.9% were boys and 49.1% girls. About 36.4% lived in urban localities and 63.6% in rural areas. About 55.8% of the mothers of the sampled children were illiterate and 42.5% children belonged to the lowest two wealth quintiles. 6 NATIONAL NUTRITION SURVEY 2018 - KFR NUTRITIONAL STATUS OF CHILDREN UNDER FIVE YEARS OF AGE STUNTING UNDERWEIGHT WASTING OVERWEIGHT In Pakistan, four out of ten children under five years of age are stunted while 17.7% suffer from wasting. The double burden of malnutrition is becoming increasingly apparent, with almost one in three children underweight (28.9%) alongside a high prevalence of overweight (9.5%) in the same age group. The prevalence of overweight among children under five has almost doubled over seven years, increasing from 5% in 2011 to 9.5% in 2018. Prevalence of Malnutrition (Children Under Five) Prevalence of Malnutrition by Locality (Urban/Rural) Stunted 34.8% Wasted 16.2% Underweight 24% Overweight 9.6% RURAL NATIONAL NUTRITION SURVEY 2018 - KFR 7 The pattern of distribution of malnutrition among boys and girls remains the same, with boys being more affected than girls by all forms of malnutrition. Children living in rural areas suffer more from under nutrition (wasting, stunting and wasting) than their peers in urban areas. Overweight affects children equally, irrespective of locality. Prevalence of Malnutrition by Gender 8 NATIONAL NUTRITION SURVEY 2018 - KFR STUNTING Stunting is a major problem in Pakistan, with 12 million children with low height for age. To ensure that this form of malnutrition does not continue to compromise the human capital required to sustain the socioeconomic development of Pakistan, stunting reduction is a top national priority. The national average (40.2%) masks provincial disparities. The prevalence of stunting varies from 32.6% in ICT to 48.3% in KP-NMD. The prevalence of stunting among young children in Sindh, Balochistan, KP-NMD and GB is higher than the national average. Prevalence of Stunting by Province/Region The prevalence of stunting improved from 1965 (48%) to 1994 (36.3%) but deteriorated from 2001 (41.6%) to 2011 (43.7%). In 2018, at 40.2%, it remains at a global critical level. The average annual reduction rate is estimated at 0.5%, too slow to significantly reduce the stunting rate in Pakistan. Trends of Stunting in Pakistan NATIONAL NUTRITION SURVEY 2018 - KFR 9 WASTING Since 1997, the prevalence of low weight for height among young children is on the rise, from 8.6% in 1997 to 15.1% in 2011 and 17.7% in 2018. Despite improvements in other socioeconomic indicators, acute malnutrition remains in a state of nutrition emergency. This is the highest rate of wasting in Pakistan’s history. Prevalence of Wasting by Province/Region 17.7% 15.1% 14.3% 11.8% 11% 10.8% 8.6% Trends of Wasting NNS: 1985-7 NNS: 1990-4 NSWP: 1965 MNS: 1997 NNS: 2001 NNS: 2011 NNS: 2018 in Pakistan This form of malnutrition is most prevalent in Sindh (23.3%) and KP-NMD (23.1%), whereas GB and ICT have the lowest proportion of children with wasting, at 9.4% and 12.1% respectively. Sindh, Balochistan and KP-NMD have a higher prevalence of wasting than the national average. The prevalence of wasting among children under five in all provinces/regions excluding ICT and GB exceeds the emergency threshold (15%). 10 NATIONAL NUTRITION SURVEY 2018 - KFR UNDERWEIGHT The prevalence of underweight among children under five years of age (i.e. weight for age below 2 z-score) is high in all provinces/regions, from 19.2% in ICT to 41.3% in Sindh. The prevalence of underweight is below 20% only in ICT. Prevalence of Underweight by Province/Region OVERWEIGHT The study estimated the proportion of overweight children under five to be 9.5%, twice the target set by the World Health Assembly. Prevalence is highest in KP-NMD (18.7%) and Balochistan (16.7%), and lowest in Sindh (5.2%) and ICT (5.8%). The prevalence of overweight among young children exceeds 10% in KP, Balochistan, KP-NMD, AJK and GB. Prevalence of Overweight by Province/Region NATIONAL NUTRITION SURVEY 2018 - KFR 11 MICRONUTRIENT DEFICIENCIES IN CHILDREN UNDER FIVE YEARS OF AGE Anaemia in Children Under Five More than half (53.7%) of Pakistani children are anaemic and 5.7% are severely anaemic. The prevalence of anaemia is slightly higher (54.2%) amongst boys than girls (53.1%). Children in rural areas are more likely to be anaemic (56.5%) than in urban areas (48.9%). A similar pattern was observed for severe anaemia (rural: 5.9%; urban: 5.2%). Trends of Anaemia in Pakistan The prevalence of anaemia has been consistently high since 2001 when it stood at 50.9%, then rose to 61.9% in 2011, and declined to 53.7% in 2018. 12 NATIONAL NUTRITION SURVEY 2018 - KFR Iron Deficiency Anaemia Among Zinc Deficiency Among Children Under Children Under Five Five The prevalence of iron deficiency anaemia is The prevalence of zinc deficiency is 18.6%, 28.6% with a slightly higher proportion (29.1%) with similar proportions among boys and girls. among boys than girls, and in rural (28.9%) Rural children have a slightly higher prevalence than urban populations. (19.5%) than those in urban areas (17.1%). Vitamin A Deficiency Among Children Under Five About 51.5% of children have vitamin A deficiency, of whom 12.1% have a severe deficiency. Prevalence is slightly higher (51.7%) among boys than in girls (51.3%). Vitamin D Deficiency Among Children Under Five A high prevalence (62.7%) of vitamin D deficiency was observed. A significant proportion (13.2%) of children have a severe deficiency. The prevalence is slightly higher (63.1%) among girls than boys (62.4%). NATIONAL NUTRITION SURVEY 2018 - KFR 13 PROGRAMME COVERAGE DEWORMING Only 13.1% children aged 24–59 months were reported to have been given deworming medication in the six months prior to the survey, with lower coverage in urban (10.7%) than in rural (14.5%) settings. Deworming by Locality (Urban/Rural) Deworming by Province/Region Coverage of deworming medication is highest in GB (14.2%) and Punjab (14.1%) and lowest in ICT (6.5%) and KP-NMD (6.7%). 14 NATIONAL NUTRITION SURVEY 2018 - KFR INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES BREASTFEEDING COMPLEMENTARY FEEDING NNS 2018 finds that early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding show an upward trend from 2011, but most indicators related to complementary feeding are declining except the proportion of children receiving an adequately diversified diet. BREASTFEEDING While there has been a steady increase in the proportion of children receiving breastmilk during the first hour after birth between 2011 and 2018, the trend for exclusive breastfeeding is not linear. From 50% in 2001, it decreased to 37.7% in 2011 and increased again to 48% in 2018, bringing Pakistan close to the World Health Assembly target of 50%. Breastfeeding Trends Nearly half (45.8%) of Pakistani babies start Early initiation of breastfeeding breastfeeding within the first hour of birth, an (within first hour of birth) improvement of 6 percentage points from 2011. The practice of early initiation of breastfeeding is only three percentage points higher in urban areas than in rural areas. NATIONAL NUTRITION SURVEY 2018 - KFR 15 Early Initiation of Breastfeeding (within first hour of birth) by Province/Region The practice of early initiation of breastfeeding varies from 20.1% in GB to 61.1% in Balochistan. Early Initiation of Breastfeeding (within first hour of birth) by Wealth Quintile There is no significant correlation found between wealth and early initiation of breastfeeding. 16 NATIONAL NUTRITION SURVEY 2018 - KFR Exclusive Breastfeeding by Province and Region The proportion of children who are exclusively breastfed for the first six months of life is highest in KP (60.7%) and KP-NMD (59.0%), and lowest in AJK (42.1%) and Balochistan (43.9%) respectively. Breastfeeding Practices in Pakistan Prevalence of the practice of continued breastfeeding is highest at one year of age (68.4%) and thereafter decreases to 56.5% at two years of age. Relative to the rates in 2011 this represents a decrease from 77.3% and an increase from 54.3%, respectively. NATIONAL NUTRITION SURVEY 2018 - KFR 17 COMPLEMENTARY FEEDING PRACTICES IN PAKISTAN Age-appropriate complementary feeding is an essential addition to breastfeeding after a child is six months of age. Quality complementary feeding is measured using three indicators: minimum dietary diversity, minimum meal frequency and minimum acceptable diet. NNS 2018 found all indicators to be far below acceptable levels. Age-Appropriate Complementary Feeding by Gender Only one of every three young children receives complementary food between 6–8 months of age. A smaller proportion of boys (34.6%) are introduced to complementary food at the right age compared to girls (37.3%). Some provinces/regions (Sindh and KP-NMD) perform better than others but timely introduction of complementary feeding needs significant improvement in across Pakistan. 18 NATIONAL NUTRITION SURVEY 2018 - KFR Age-Appropriate Complementary Feeding by Province/Region NATIONAL NUTRITION SURVEY 2018 - KFR 19 Complementary Feeding in Pakistan By Locality (Urban/Rural) 20 NATIONAL NUTRITION SURVEY 2018 - KFR Complementary Feeding Practices by Province/Region Over time, three of the four complementary indicators have declined significantly. This points to a need for robust and large-scale promotion of adequate complementary practices in Pakistan to contribute to reducing stunting among young children. Only one in seven children (14.2%) aged 6–23 months receive a meal with minimum dietary diversity, with at least four different food groups. One in four children (18.2%) receives the minimum number of meals a day. Complementary foods that meet the requirements of a minimum acceptable diet to ensure optimal growth and development for children aged 6–23 months are provided to less than one in 20 children (3.6%). More children in urban areas receive adequate complementary foods than their peers in rural areas, but rates are critically low in both localities. NATIONAL NUTRITION SURVEY 2018 - KFR 21 Trends in Complementary Feeding All complementary feeding indicators are far below acceptable levels 22 NATIONAL NUTRITION SURVEY 2018 - KFR DISABILITY AMONG CHILDREN AGED 24-59 MONTHS The Washington Group on Disability Statistics determines functional disability among children aged 2–5 years based on six core functional domains. NNS 2018 found that 12.7% children have a functional disability in one of these six domains. Around 1.2% demonstrate functional disability in seeing, 1.5% in hearing, 2.6% in walking, 4.5% in remembering, 8.5% in selfcare and 5.6% in communication. Functional Disability Among Children Aged 24-59 Months In Pakistan, boys are more likely to have a functional disability related to remembering. For all other types of functional disability, boys and girls are equally affected. Functional Disability Among Children Aged 24-59 Months by Gender ADOLESCENT GIRLS & BOYS (10-19 YEARS) About two-thirds of the sampled adolescent girls aged 10–19 years (62.9%) lived in rural areas and 37.1% in urban areas. The majority of girls (94.7%) in the survey sample were never married while 5.2% were currently married. A large proportion (38%) of adolescent girls belonged to the two highest wealth quintiles. Of the sampled adolescent boys (10–19 years) 63.5% lived in rural areas and 36.5% in urban areas. 24 NATIONAL NUTRITION SURVEY 2018 - KFR ADOLESCENTS NUTRITION (10-19 YEARS) Nutritional Status of Adolescent Girls and Boys NNS 2018 shows that almost one in eight adolescent girls is underweight. Adolescent boys are more affected than adolescent girls, with one in five underweight. More adolescent girls are overweight compared to their male peers, at 11.4% and 10.2% respectively. Obesity is a public health issue of concern in Pakistan, with 7.7% of adolescent boys and 5.5% of adolescent girls affected. Overweight and obesity affect adolescents similarly in both rural and urban areas of Pakistan. NATIONAL NUTRITION SURVEY 2018 - KFR 25 Nutritional Status of Adolescent Girls and Boys by Locality (Urban/Rural) 26 NATIONAL NUTRITION SURVEY 2018 - KFR Across all of Pakistan’s provinces/regions, the double burden of malnutrition – high prevalence of underweight combined with high prevalence of overweight or obesity – is a major concern and requires serious consideration to curb the incidence of noncommunicable diseases. Nutritional Status of Adolescent Girls by Province/Region Haemoglobin Status Among Anaemia Among Adolescent Girls Adolescent Girls More than half (56.6%) of adolescent girls in Pakistan are anaemic, however only 0.9% have severe anaemia. Adolescent girls in rural areas are more likely (58.1%) to be anaemic than their counterparts in urban areas (54.2%). NATIONAL NUTRITION SURVEY 2018 - KFR 27 Nutritional Status of Adolescent Boys (BMI) by Province/Region WOMEN OF REPRODUCTIVE AGE (WRA) (15-49YEARS) Overall, 61.2% of the sampled WRA belonged to rural settings and 38.8% to urban areas. Nearly half (48.5%) were not educated while 15.5% had received higher education and 14.5% had completed secondary education. Most of the sampled WRA (72.0%) were housewives with only 1.9% skilled workers and 1.7% professionals. Most sampled WRA (21.3%) came from the richest wealth index quintile and only 17.8% belonged to the poorest quintile. 30 NATIONAL NUTRITION SURVEY 2018 - KFR WOMEN OF REPRODUCTIVE AGE (15-49 YRS) RESPONDENT CHARACTERISTICS In Pakistan WRA aged 15–49 years bear a double burden of malnutrition. One in seven (14.4%) are undernourished, a decline from 18% in 2011 to 14%, while overweight and obesity are increasing. In NNS 2011 28% were reported to be overweight or obese, rising to 37.8% 2018. Urban/rural disparity is apparent: women in rural areas are more malnourished, while overweight and obesity are higher in urban women. Nutritional Status of WRA (15-49 years) by Body Mass Index (BMI) NATIONAL NUTRITION SURVEY 2018 - KFR 31 Nutritional Status of WRA (15-49 years) by Province/Region At provincial/regional level, Sindh, Balochistan and AJK have more undernourished women while overweight and obesity are more pronounced in ICT, KP and KP-NMD. 32 NATIONAL NUTRITION SURVEY 2018 - KFR MICRONUTRIENT DEFICIENCIES IN WOMEN OF REPRODUCTIVE AGE (15-49 YRS) Anaemia among Women of Reproductive age About 41.7% of WRA are anaemic, with a slightly higher proportion in rural (44.3%) than urban settings (40.2%). Trend Analysis in Anaemia NATIONAL NUTRITION SURVEY 2018 - KFR 33 Vitamin D Deficiency The majority of WRA (79.7%) are affected by vitamin D deficiency, with 54.0% experiencing moderate vitamin D deficiency and 25.7% experiencing severe deficiency. Vitamin D deficiency is more common in urban (83.6%) than in rural settings (77.1%). Vitamin A Deficiency in Women Age 15-49 Years Over a quarter of WRA (27.3%) are deficient in vitamin A, with 22.4% experiencing moderate and 4.9% severe deficiency. This is more prevalent among WRA in rural settings (29.3%). Balochistan (34.6%) has the highest proportion of WRA with vitamin A deficiency. 34 NATIONAL NUTRITION SURVEY 2018 - KFR Iron Deficiency Anaemia in WRA - 15-49 Years About 18.2% of WRA are iron deficient. This is more pronounced among women residing in rural (18.7%) than urban (17.4%) settings. Sindh has the highest proportion of iron deficiency anaemia with about a quarter (23.8%) of all WRA affected, followed closely by Balochistan (19.0%) and Punjab (18.7%). Calcium and Zinc Deficency About 26.5% of WRA are hypocalcaemic while 0.4% are hypercalcaemic. Zinc deficiency (22.1%) is more common in rural settings (24.3%) than in urban areas (18.7%). Punjab has the highest proportion of WRA with zinc deficiency (24.1%) followed by Balochistan (23.4%) and Sindh (21.4%), while KP has the lowest prevalence (15.9%). Urinary Iodine Excretion About 17.5% of WRA have urinary iodine deficiency. Of these, 12.9% have moderate and 4.6% have severe deficiency. Both severe and moderate urine iodine deficiency is more prevalent in women in rural areas (18.6%) than in urban areas (16%). UNIVERSAL SALT IODIZATION IN PAKISTAN Salt samples were taken from 100,304 households across provinces/regions and were tested using rapid test kits to identify adequately iodized salt (≥15 ppm and