Anaemia

Anaemia

What does this indicator tell us?

The indicator anaemia has a wide variety of causes. Iron deficiency is considered to be the most common cause of anaemia; other causes include acute and chronic infections that result in inflammation and blood loss; deficiencies of other vitamins and minerals, especially folate, vitamin B₁₂ and vitamin A; and genetically inherited traits, such as thalassaemia. Other conditions (e.g. malaria and other infections, genetic disorders, and cancer) can also play a role in anaemia. The terms “iron-deficiency anaemia” and “anaemia” are often used synonymously; also, the prevalence of anaemia has often been used as a proxy for iron-deficiency anaemia, although the degree of overlap between the two varies considerably from one population to another, according to gender and age.

Anaemia prevalence among pregnant and non-pregnant women are included as primary outcome indicators in the core set of indicators for the Global nutrition monitoring framework. These indicators are used to monitor progress towards achieving Global Nutrition Target 2, which is a 50% reduction in anaemia among women of reproductive age by 2025. Anaemia in women of reproductive age and in children are also included in the WHO Global reference list of 100 core health indicators.

How is this indicator defined?

Anaemia is defined as a haemoglobin concentration below a specified cut-off point; that cut-off point depends on the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives. WHO defines anaemia in children aged under 5 years and pregnant women as a haemoglobin concentration <110 g/L at sea level, and anaemia in non-pregnant women as a haemoglobin concentration <120 g/L.

Tests to measure haemoglobin levels are easy to administer. A few drops of blood obtained by a finger-stick can be used to assess haemoglobin concentrations in the field using a portable haemoglobinometer. The test could be easily integrated into regular health or prenatal visits or household surveys, to capture women of reproductive age, although the cost of the equipment and regular calibration needs to be taken into account.

What are the consequences and implications?

Anaemia is associated with increased risks for maternal and child mortality. Iron-deficiency anaemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anaemia on the cognitive and physical development of children and on physical performance – particularly the work productivity of adults – are major concerns. Anaemia is a global problem affecting all countries. Resource-poor areas are often more heavily affected because of the prevalence of infectious diseases. Malaria, HIV/AIDS, hookworm infestation, schistosomiasis and other infections such as tuberculosis contribute to the high prevalence of anaemia in some areas.

The main risk factors for iron-deficiency anaemia include a low dietary intake of iron or poor absorption of iron from diets rich in phytates or phenolic compounds. Population groups with greater iron requirements, such as growing children and pregnant women, are particularly at risk. Overall, the most vulnerable, poorest and least educated groups are disproportionately affected by iron-deficiency anaemia.

Cut-off values for public health significance

Source: WHO (2008).

Sources of data

WHO. Global Health Observatory (GHO) data repository.

Prevalence of anaemia in pregnant women. Estimates by country. (http://apps.who.int/gho/data/view.main.ANAEMIAWOMENPWv).

Prevalence of anaemia in non-pregnant women. Estimates by country (http://apps.who.int/gho/data/view.main.ANAEMIAWOMENNPWv).

Further reading

Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative data. Lancet Global Health. 2013;1:e16–25.

WHO. Global nutrition targets 2025: anaemia policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/).

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. WHO/NMH/NHD/MNM/11.1. Geneva: World Health Organization; 2011 (http://www.who.int/vmnis/indicators/haemoglobin.pdf).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. Vitamin and Mineral Nutrition Information System (VMNIS).  (http://www.who.int/vmnis/en/).

WHO. Anaemia/iron deficiency list of publications. (http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/en/index.html).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Health conditions. Anaemia (http://www.who.int/elena/health_condition/en/#anaemia).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target (http://www.who.int/elena/global-targets/en):

Target 2: 50% reduction of anaemia in women of reproductive age (http://www.who.int/elena/global-targets/en/#anaemia).

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Anaemia

Anaemia

What does this indicator tell us?

The indicator anaemia has a wide variety of causes. Iron deficiency is considered to be the most common cause of anaemia; other causes include acute and chronic infections that result in inflammation and blood loss; deficiencies of other vitamins and minerals, especially folate, vitamin B₁₂ and vitamin A; and genetically inherited traits, such as thalassaemia. Other conditions (e.g. malaria and other infections, genetic disorders, and cancer) can also play a role in anaemia. The terms “iron-deficiency anaemia” and “anaemia” are often used synonymously; also, the prevalence of anaemia has often been used as a proxy for iron-deficiency anaemia, although the degree of overlap between the two varies considerably from one population to another, according to gender and age.

Anaemia prevalence among pregnant and non-pregnant women are included as primary outcome indicators in the core set of indicators for the Global nutrition monitoring framework. These indicators are used to monitor progress towards achieving Global Nutrition Target 2, which is a 50% reduction in anaemia among women of reproductive age by 2025. Anaemia in women of reproductive age and in children are also included in the WHO Global reference list of 100 core health indicators.

How is this indicator defined?

Anaemia is defined as a haemoglobin concentration below a specified cut-off point; that cut-off point depends on the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives. WHO defines anaemia in children aged under 5 years and pregnant women as a haemoglobin concentration <110 g/L at sea level, and anaemia in non-pregnant women as a haemoglobin concentration <120 g/L.

Tests to measure haemoglobin levels are easy to administer. A few drops of blood obtained by a finger-stick can be used to assess haemoglobin concentrations in the field using a portable haemoglobinometer. The test could be easily integrated into regular health or prenatal visits or household surveys, to capture women of reproductive age, although the cost of the equipment and regular calibration needs to be taken into account.

What are the consequences and implications?

Anaemia is associated with increased risks for maternal and child mortality. Iron-deficiency anaemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anaemia on the cognitive and physical development of children and on physical performance – particularly the work productivity of adults – are major concerns. Anaemia is a global problem affecting all countries. Resource-poor areas are often more heavily affected because of the prevalence of infectious diseases. Malaria, HIV/AIDS, hookworm infestation, schistosomiasis and other infections such as tuberculosis contribute to the high prevalence of anaemia in some areas.

The main risk factors for iron-deficiency anaemia include a low dietary intake of iron or poor absorption of iron from diets rich in phytates or phenolic compounds. Population groups with greater iron requirements, such as growing children and pregnant women, are particularly at risk. Overall, the most vulnerable, poorest and least educated groups are disproportionately affected by iron-deficiency anaemia.

Cut-off values for public health significance

Source: WHO (2008).

Sources of data

WHO. Global Health Observatory (GHO) data repository.

Prevalence of anaemia in pregnant women. Estimates by country. (http://apps.who.int/gho/data/view.main.ANAEMIAWOMENPWv).

Prevalence of anaemia in non-pregnant women. Estimates by country (http://apps.who.int/gho/data/view.main.ANAEMIAWOMENNPWv).

Further reading

Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative data. Lancet Global Health. 2013;1:e16–25.

WHO. Global nutrition targets 2025: anaemia policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/).

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. WHO/NMH/NHD/MNM/11.1. Geneva: World Health Organization; 2011 (http://www.who.int/vmnis/indicators/haemoglobin.pdf).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. Vitamin and Mineral Nutrition Information System (VMNIS).  (http://www.who.int/vmnis/en/).

WHO. Anaemia/iron deficiency list of publications. (http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/en/index.html).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Health conditions. Anaemia (http://www.who.int/elena/health_condition/en/#anaemia).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target (http://www.who.int/elena/global-targets/en):

Target 2: 50% reduction of anaemia in women of reproductive age (http://www.who.int/elena/global-targets/en/#anaemia).

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Low birth weight

Low birth weight

What does this indicator tell us?

At a population level, the proportion of infants with a low birth weight is an indicator of a multifaceted public health problem that includes long-term maternal malnutrition, ill-health and poor health care in pregnancy.

Low birth weight is included as a primary outcome indicator in the core set of indicators for the Global nutrition monitoring framework. It is also included in the WHO Global reference list of 100 core health indicators.

How is this indicator defined?

Low birth weight has been defined by WHO as weight at birth of <2500 g (5.5 pounds).

What are the consequences and implications?

Low birth weight is caused by intrauterine growth restriction, prematurity or both. It contributes to a range of poor health outcomes; for example, it is closely associated with fetal and neonatal mortality and morbidity, inhibited growth and cognitive development, and noncommunicable diseases (NCDs) later in life. Low birth weight infants are about 20 times more likely to die than heavier infants.

Low birth weight is more common in developing than developed countries. However, data on low birth weight in developing countries is often limited because a significant portion of deliveries occur in homes or small health facilities, where cases of infants with low birth weight often go unreported. These cases are not reflected in official figures and may lead to a significant underestimation of the prevalence of low birth weight.

Source of data

UNICEF data: monitoring the situation of children and women (https://data.unicef.org/).

Further reading

UNICEF-WHO Low birthweight estimates: Levels and trends 2000–2015. Geneva: World Health Organization; 2019 (https://www.who.int/nutrition/publications/UNICEF-WHOlowbirthweight-estimates-2019/en/).

WHO. Global nutrition targets 2025: low birth weight policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_lbw/en/).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. Feto-maternal nutrition and low birth weight. (http://www.who.int/nutrition/topics/feto_maternal/en/index.html).

WHO. Global targets 2025 to improve maternal, infant and young child nutrition (http://who.int/nutrition/global-target-2025/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. (http://www.who.int/elena/global-targets/en).

Target 3: 30% reduction in low birth weight (http://www.who.int/elena/global-targets/en/#lowbirthweight).

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Malnutrition in children

Stunting, wasting, overweight and underweight

What do these indicators tell us?

The indicators stunting, wasting, overweight and underweight are used to measure nutritional imbalance; such imbalance results in either undernutrition (assessed from stunting, wasting and underweight) or overweight. Child growth is internationally recognized as an important indicator of nutritional status and health in populations.

The percentage of children with a low height-for-age (stunting) reflects the cumulative effects of undernutrition and infections since birth, and even before birth. This measure can therefore be interpreted as an indication of poor environmental conditions or long-term restriction of a child’s growth potential. The percentage of children who have low weight-for-age (underweight) can reflect wasting (i.e. low weight-for-height), indicating acute weight loss or stunting, or both. Thus, underweight is a composite indicator that may be difficult to interpret.

Stunting, wasting and overweight in children aged under 5 years are included as primary outcome indicators in the core set of indicators for the Global nutrition monitoring framework to monitor progress towards reaching Global Nutrition Targets 1, 4 and 6. These three indicators are also included in WHO’s Global reference list of 100 core health indicators.

How are these indicators defined?

These indicators are defined as follows:

·   stunting – height-for-age ≤-2 SD of the WHO Child growth standards median;

·   wasting – weight-for-height ≤-2 SD of the WHO Child growth standards median; and

·   overweight – weight-for-height ≥+2 SD of the WHO Child growth standards median.

·   underweight – weight-for-age ≤-2 standard deviations (SD) of the WHO Child growth standards median;

What are the consequences and implications?

Stunting – Children who suffer from growth retardation as a result of poor diets or recurrent infections tend to be at greater risk for illness and death. Stunting is the result of long-term nutritional deprivation, and often results in delayed mental development, poor school performance and reduced intellectual capacity. In turn, this affects economic productivity at the national level. Women of short stature are at greater risk for obstetric complications because of a smaller pelvis. Also, small women are at greater risk of delivering an infant with low birth weight, contributing to the intergenerational cycle of malnutrition, because infants of low birth weight or retarded intrauterine growth tend be smaller as adults.

Wasting – Wasting in children is a symptom of acute undernutrition, usually as a consequence of insufficient food intake or a high incidence of infectious diseases, especially diarrhoea. In turn, wasting impairs the functioning of the immune system and can lead to increased severity and duration of, and susceptibility to, infectious diseases, and an increased risk of death.

Overweight – Childhood obesity is associated with a higher probability of obesity in adulthood, which can lead to a variety of disabilities and diseases, such as diabetes and cardiovascular diseases. The risks for most noncommunicable diseases (NCDs) resulting from obesity depend partly on the age at onset and the duration of obesity. Obese children and adolescents are likely to suffer from both short-term and long-term health consequences, the most significant being: cardiovascular diseases, mainly heart disease and stroke; diabetes; musculoskeletal disorders, especially osteoarthritis; and, cancers of the endometrium, breast and colon.

Underweight – Weight is easy to measure; hence, this is the indicator for which most data have been collected in the past. The mortality risk is increased in children who are even mildly underweight, and the risk is even greater in severely underweight children.

Cut-off values for public health significance

Source: de Onis et al. (2018).

Source of data

WHO. Global database on child growth and malnutrition (http://www.who.int/nutgrowthdb/en/).

Further reading

de Onis M, Borghi E, Arimond M, Webb P, Croft T, Saha K et al. Prevalence thresholds for wasting, overweight and stunting in children under 5 years. Public Health Nutrition. 2018;1–5. doi:10.1017/S1368980018002434.

WHO. Global nutrition targets 2025: stunting policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_stunting/en/).

WHO, United Nations Children’s Fund (UNICEF), World Food Programme (WFP). Global nutrition targets 2025: wasting policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_wasting/en/).

WHO. Global nutrition targets 2025: childhood overweight policy brief. Geneva: World Health Organization; 2014 (http://www.who.int/nutrition/publications/globaltargets2025_policybrief_overweight/en/).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. Child growth standards. Publications and peer-reviewed articles. (http://www.who.int/childgrowth/publications/en/).

WHO, UNICEF. Recommendations for data collection, analysis and reporting on anthropometric indicators in children under 5 years old. Geneva: World Health Organization; 2019 (https://www.who.int/nutrition/publications/anthropometry-data-quality-report/en/).

UNICEF–WHO–The World Bank: Joint child malnutrition estimates – levels and trends. (http://www.who.int/nutgrowthdb/estimates/en/).

WHO. Global targets 2025 to improve maternal, infant and young child nutrition. (http://who.int/nutrition/global-target-2025/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. (http://www.who.int/elena/global-targets/en).

Target 1: 40% reduction in the number of children under-5 who are stunted (http://www.who.int/elena/global-targets/en/#stunting).

Target 4: No increase in childhood overweight (http://www.who.int/elena/global-targets/en/#childhoodoverweight).

Target 6: Reduce and maintain childhood wasting to less than 5% (http://www.who.int/elena/global-targets/en/#wasting).

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Children exclusively breastfed under 6 months

Infant and young child feeding

To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO and UNICEF recommend:

• initiation of breastfeeding within the first hour of life;

• exclusive breastfeeding (i.e. only breast milk with no additional food or drink, not even water);

• breastfeeding on demand, as often the child wants, day and night; and

• no use of bottles, teats or pacifiers.

The recommendations for feeding infants and young children (6–23 months) include:

• continued breastfeeding;

• introduction of solid, semisolid or soft foods at 6 months;

• appropriate food diversity (at least five food groups per day);

• appropriate frequency of meals: two to three times a day between 6 and 8 months, increasing to three to four times a day between 9 and 23 months with nutritious snacks offered once or twice a day, as desired;

• safe preparation of foods; and

• feeding infants in response to their cues.

The caring practice indicators for infant and young child feeding available on the NLIS country profiles include:

• proportion of children aged 0–23 months who were put to the breast within 1 h of birth;
• proportion of infants under 6 months who are exclusively breastfed;
• proportion of infants aged 6–8 months who receive solid, semisolid or soft foods;
• proportion of children aged 6–23 months who receive a minimum dietary diversity; and
• proportion of children aged 6–23 months who receive a minimum acceptable

Early initiation of breastfeeding

What does this indicator tell us?

This indicator is the percentage of infants who are put to the breast within 1 hour of birth.

How is it defined?

Early initiation of breastfeeding is defined as the proportion of children born in the past 24 months who were put to the breast within 1 hour of birth.

What are the consequences and implications?

Breastfeeding improves child health, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

Infants under 6 months who are exclusively breastfed

What does this indicator tell us?

This indicator is the percentage of infants aged 0-5 months who are exclusively breastfed.

How is it defined?

It is the proportion of infants aged 0–5 months who are fed exclusively on breast milk and no other food or drink, including water. The infant is however, allowed to receive ORS and drops or syrups containing vitamins, minerals and medicine.

What are the consequences and implications?

Exclusive breastfeeding is an unequalled way of providing the ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process, with important health benefits for mothers. An expert review of evidence showed that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants.

Breast milk is the natural first food for infants. It provides all the energy and nutrients that the infant needs for the first months of life. It continues to provide up to one half or more of a child’s nutritional needs during the second half of the first year and up to one third during the second year of life.

Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment

Infants aged 6-8 months who receive solid, semisolid or soft foods

What does this indicator tell us?

The indicator is the percentage of infants between 6-8 months of age who start solid, semisolid or soft foods. WHO recommends starting complementary feeding at 6 months of age.

How is it defined?

It is defined as the proportion of infants aged 6-8 months who receive solid, semisolid or soft foods during the previous day.

What are the consequences and implications?

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. The transition from exclusive breastfeeding to family foods, referred to as 'complementary feeding', typically occurs between 6 and 18-24 months of age. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

Children aged 6–23 months who receive a minimum dietary diversity

Children aged 6-23 months who receive a minimum acceptable diet

What does this indicator tell us?

This indicator is the percentage of children aged 6-23 months who receive a minimum acceptable diet.

Proportion of children aged 6-23 months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

How is it defined?

The composite indicator of a minimum acceptable diet is calculated from:

• the proportion of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day and

• the proportion of non-breastfed children aged 6–23 months who received at least two milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day.

Dietary diversity is present when the diet contained five or more of the following food groups:

• breast milk;

• grains, roots and tubers;

• legumes and nuts;

• dairy products (milk, yogurt, cheese);

• flesh foods (meat, fish, poultry, liver or other organs);

• eggs;

• vitamin A-rich fruits and vegetables; and

  other fruits and vegetables.

   

The minimum daily meal frequency is defined as:

• twice for breastfed infants aged 6–8 months,
• three times for breastfed children aged 9–23 months and
• four times for non-breastfed children aged 6–23 months.

What are the consequences and implications?

A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6–23 months. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality

Source of all infant and young child feeding indicators

UNICEF. UNICEF Data: Monitoring the situation of Children and Women. https://data.unicef.org.

Further reading

WHO. Infant and young child feeding list of publications. http://www.who.int/nutrition/publications/infantfeeding/en/index.html.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/.

WHO. E-Library of Evidence for Nutrition Actions (eLENA):

• Breastfeeding: early initiation. http://www.who.int/entity/elena/titles/early_breastfeeding/en/index.html.

• Breastfeeding: exclusive breastfeeding. http://www.who.int/entity/elena/titles/exclusive_breastfeeding/en/index.html.

• Breastfeeding: continued breastfeeding. http://www.who.int/entity/elena/titles/continued_breastfeeding/en/index.html.

• Complementary feeding. http://www.who.int/entity/elena/titles/complementary_feeding/en/index.html.

WHO. WHO Global Data Bank on Infant and Young Child Feeding. http://www.who.int/nutrition/databases/infantfeeding/en/index.html.

WHO & UNICEF. Global Nutrition Monitoring Framework. Operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017. http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/.

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Children exclusively breastfed under 6 months

Infant and young child feeding

To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO and UNICEF recommend:

• initiation of breastfeeding within the first hour of life;

• exclusive breastfeeding (i.e. only breast milk with no additional food or drink, not even water);

• breastfeeding on demand, as often the child wants, day and night; and

• no use of bottles, teats or pacifiers.

The recommendations for feeding infants and young children (6–23 months) include:

• continued breastfeeding;

• introduction of solid, semisolid or soft foods at 6 months;

• appropriate food diversity (at least five food groups per day);

• appropriate frequency of meals: two to three times a day between 6 and 8 months, increasing to three to four times a day between 9 and 23 months with nutritious snacks offered once or twice a day, as desired;

• safe preparation of foods; and

• feeding infants in response to their cues.

The caring practice indicators for infant and young child feeding available on the NLIS country profiles include:

• proportion of children aged 0–23 months who were put to the breast within 1 h of birth;
• proportion of infants under 6 months who are exclusively breastfed;
• proportion of infants aged 6–8 months who receive solid, semisolid or soft foods;
• proportion of children aged 6–23 months who receive a minimum dietary diversity; and
• proportion of children aged 6–23 months who receive a minimum acceptable

Early initiation of breastfeeding

What does this indicator tell us?

This indicator is the percentage of infants who are put to the breast within 1 hour of birth.

How is it defined?

Early initiation of breastfeeding is defined as the proportion of children born in the past 24 months who were put to the breast within 1 hour of birth.

What are the consequences and implications?

Breastfeeding improves child health, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

Infants under 6 months who are exclusively breastfed

What does this indicator tell us?

This indicator is the percentage of infants aged 0-5 months who are exclusively breastfed.

How is it defined?

It is the proportion of infants aged 0–5 months who are fed exclusively on breast milk and no other food or drink, including water. The infant is however, allowed to receive ORS and drops or syrups containing vitamins, minerals and medicine.

What are the consequences and implications?

Exclusive breastfeeding is an unequalled way of providing the ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process, with important health benefits for mothers. An expert review of evidence showed that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants.

Breast milk is the natural first food for infants. It provides all the energy and nutrients that the infant needs for the first months of life. It continues to provide up to one half or more of a child’s nutritional needs during the second half of the first year and up to one third during the second year of life.

Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment

Infants aged 6-8 months who receive solid, semisolid or soft foods

What does this indicator tell us?

The indicator is the percentage of infants between 6-8 months of age who start solid, semisolid or soft foods. WHO recommends starting complementary feeding at 6 months of age.

How is it defined?

It is defined as the proportion of infants aged 6-8 months who receive solid, semisolid or soft foods during the previous day.

What are the consequences and implications?

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. The transition from exclusive breastfeeding to family foods, referred to as 'complementary feeding', typically occurs between 6 and 18-24 months of age. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

Children aged 6–23 months who receive a minimum dietary diversity

Children aged 6-23 months who receive a minimum acceptable diet

What does this indicator tell us?

This indicator is the percentage of children aged 6-23 months who receive a minimum acceptable diet.

Proportion of children aged 6-23 months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

How is it defined?

The composite indicator of a minimum acceptable diet is calculated from:

• the proportion of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day and

• the proportion of non-breastfed children aged 6–23 months who received at least two milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day.

Dietary diversity is present when the diet contained five or more of the following food groups:

• breast milk;

• grains, roots and tubers;

• legumes and nuts;

• dairy products (milk, yogurt, cheese);

• flesh foods (meat, fish, poultry, liver or other organs);

• eggs;

• vitamin A-rich fruits and vegetables; and

  other fruits and vegetables.

   

The minimum daily meal frequency is defined as:

• twice for breastfed infants aged 6–8 months,
• three times for breastfed children aged 9–23 months and
• four times for non-breastfed children aged 6–23 months.

What are the consequences and implications?

A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6–23 months. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality

Source of all infant and young child feeding indicators

UNICEF. UNICEF Data: Monitoring the situation of Children and Women. https://data.unicef.org.

Further reading

WHO. Infant and young child feeding list of publications. http://www.who.int/nutrition/publications/infantfeeding/en/index.html.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/.

WHO. E-Library of Evidence for Nutrition Actions (eLENA):

• Breastfeeding: early initiation. http://www.who.int/entity/elena/titles/early_breastfeeding/en/index.html.

• Breastfeeding: exclusive breastfeeding. http://www.who.int/entity/elena/titles/exclusive_breastfeeding/en/index.html.

• Breastfeeding: continued breastfeeding. http://www.who.int/entity/elena/titles/continued_breastfeeding/en/index.html.

• Complementary feeding. http://www.who.int/entity/elena/titles/complementary_feeding/en/index.html.

WHO. WHO Global Data Bank on Infant and Young Child Feeding. http://www.who.int/nutrition/databases/infantfeeding/en/index.html.

WHO & UNICEF. Global Nutrition Monitoring Framework. Operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017. http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/.

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Wasting

Stunting, wasting, overweight and underweight

What do these indicators tell us?

The indicators stunting, wasting, overweight and underweight are used to measure nutritional imbalance; such imbalance results in either undernutrition (assessed from stunting, wasting and underweight) or overweight. Child growth is internationally recognized as an important indicator of nutritional status and health in populations.

The percentage of children with a low height-for-age (stunting) reflects the cumulative effects of undernutrition and infections since birth, and even before birth. This measure can therefore be interpreted as an indication of poor environmental conditions or long-term restriction of a child’s growth potential. The percentage of children who have low weight-for-age (underweight) can reflect wasting (i.e. low weight-for-height), indicating acute weight loss or stunting, or both. Thus, underweight is a composite indicator that may be difficult to interpret.

Stunting, wasting and overweight in children aged under 5 years are included as primary outcome indicators in the core set of indicators for the Global nutrition monitoring framework to monitor progress towards reaching Global Nutrition Targets 1, 4 and 6. These three indicators are also included in WHO’s Global reference list of 100 core health indicators.

How are these indicators defined?

These indicators are defined as follows:

·   stunting – height-for-age ≤-2 SD of the WHO Child growth standards median;

·   wasting – weight-for-height ≤-2 SD of the WHO Child growth standards median; and

·   overweight – weight-for-height ≥+2 SD of the WHO Child growth standards median.

·   underweight – weight-for-age ≤-2 standard deviations (SD) of the WHO Child growth standards median;

What are the consequences and implications?

Stunting – Children who suffer from growth retardation as a result of poor diets or recurrent infections tend to be at greater risk for illness and death. Stunting is the result of long-term nutritional deprivation, and often results in delayed mental development, poor school performance and reduced intellectual capacity. In turn, this affects economic productivity at the national level. Women of short stature are at greater risk for obstetric complications because of a smaller pelvis. Also, small women are at greater risk of delivering an infant with low birth weight, contributing to the intergenerational cycle of malnutrition, because infants of low birth weight or retarded intrauterine growth tend be smaller as adults.

Wasting – Wasting in children is a symptom of acute undernutrition, usually as a consequence of insufficient food intake or a high incidence of infectious diseases, especially diarrhoea. In turn, wasting impairs the functioning of the immune system and can lead to increased severity and duration of, and susceptibility to, infectious diseases, and an increased risk of death.

Overweight – Childhood obesity is associated with a higher probability of obesity in adulthood, which can lead to a variety of disabilities and diseases, such as diabetes and cardiovascular diseases. The risks for most noncommunicable diseases (NCDs) resulting from obesity depend partly on the age at onset and the duration of obesity. Obese children and adolescents are likely to suffer from both short-term and long-term health consequences, the most significant being: cardiovascular diseases, mainly heart disease and stroke; diabetes; musculoskeletal disorders, especially osteoarthritis; and, cancers of the endometrium, breast and colon.

Underweight – Weight is easy to measure; hence, this is the indicator for which most data have been collected in the past. The mortality risk is increased in children who are even mildly underweight, and the risk is even greater in severely underweight children.

Cut-off values for public health significance

Source: de Onis et al. (2018).

Source of data

WHO. Global database on child growth and malnutrition (http://www.who.int/nutgrowthdb/en/).

Further reading

de Onis M, Borghi E, Arimond M, Webb P, Croft T, Saha K et al. Prevalence thresholds for wasting, overweight and stunting in children under 5 years. Public Health Nutrition. 2018;1–5. doi:10.1017/S1368980018002434.

WHO. Global nutrition targets 2025: stunting policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_stunting/en/).

WHO, United Nations Children’s Fund (UNICEF), World Food Programme (WFP). Global nutrition targets 2025: wasting policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_wasting/en/).

WHO. Global nutrition targets 2025: childhood overweight policy brief. Geneva: World Health Organization; 2014 (http://www.who.int/nutrition/publications/globaltargets2025_policybrief_overweight/en/).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. Child growth standards. Publications and peer-reviewed articles. (http://www.who.int/childgrowth/publications/en/).

WHO, UNICEF. Recommendations for data collection, analysis and reporting on anthropometric indicators in children under 5 years old. Geneva: World Health Organization; 2019 (https://www.who.int/nutrition/publications/anthropometry-data-quality-report/en/).

UNICEF–WHO–The World Bank: Joint child malnutrition estimates – levels and trends. (http://www.who.int/nutgrowthdb/estimates/en/).

WHO. Global targets 2025 to improve maternal, infant and young child nutrition. (http://who.int/nutrition/global-target-2025/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. (http://www.who.int/elena/global-targets/en).

Target 1: 40% reduction in the number of children under-5 who are stunted (http://www.who.int/elena/global-targets/en/#stunting).

Target 4: No increase in childhood overweight (http://www.who.int/elena/global-targets/en/#childhoodoverweight).

Target 6: Reduce and maintain childhood wasting to less than 5% (http://www.who.int/elena/global-targets/en/#wasting).

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Children with diarrhoea receiving oral rehydration therapy (ORT)

Children <5 years with diarrhoea receiving oral rehydration solution (ORS)

What does this indicator tell us?

This indicator is the prevalence of children with diarrhoea who received oral rehydration solution (ORS). The percentage of children aged under 5 years with diarrhoea receiving ORS is an intermediate outcome indicator of the Global Nutrition Targets. Coverage of diarrhoea treatment is also included in the Global reference list of 100 core health indicators.

How is this indicator defined?

This indicator is the proportion of children aged 0–59 months who had diarrhoea in the previous 2 weeks and who received ORS (fluids made from ORS packets or pre-packaged ORS fluids). Diarrhoea is defined as the passage of three or more loose or liquid stools per day.

What are the consequences and implications?

Diarrhoeal diseases remain one of the major causes of mortality among children aged under 5 years, accounting for 9% of deaths among children worldwide. Most of the deaths in children from diarrhoea could be averted by using ORS and zinc supplementation during episodes of diarrhoea, and basic interventions to improve drinking water, sanitation and hygiene (WASH). It is estimated that ORS alone can prevent 93% of deaths due to diarrhoea, and zinc supplementation can decrease deaths from diarrhoea by 23%.

Source of data

WHO. Global Health Observatory (GHO) data repository. Preventing child deaths. Data by country (http://apps.who.int/gho/data/view.main.1600).

Further reading

WHO. Diarrhoeal disease. Fact sheet. Geneva: World Health Organization; 2017 (http://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

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Underweight in women aged 15-49 years

Moderate and severe thinness, underweight, overweight and obesity

What do these indicators tell us?

The values for body mass index (BMI) are age-independent for adult populations, and are the same for both genders. However, BMI may not correspond to the same degree of fatness in different populations, in part because of different body proportions. The health risks associated with increasing BMI are continuous, and the interpretation of the BMI grading in relation to risk may differ for different populations.

Proportions of underweight in women aged 15–49 years and of overweight in women aged 18 years or more are included as intermediate outcome indicators in the core set of indicators for the Global nutrition monitoring framework. Adult overweight is also included in the NCD global monitoring framework, and in the WHO Global reference list of 100 core health indicators. Underweight in women aged 15–49 years is included as an additional indicator in the WHO Global reference list of 100 core health indicators.

How are these indicators defined?

BMI is a simple index of weight-to-height that is commonly used to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of the height in metres (kg/m²). For example, an adult who weighs 58 kg and has a height of 1.70 m will have a BMI of 20.1, where BMI = 58 kg/(1.70 m ´ 1.70 m) = 20.1. BMI values indicate the following:

• BMI <17.0: moderate and severe thinness
• BMI <18.5: underweight
• BMI 18.5–24.9: normal weight
• BMI ≥25.0: overweight
• BMI ≥30.0: obesity.

What are the consequences and implications?

Moderate and severe thinness – A BMI <17.0 indicates moderate and severe thinness in adult populations. It has been clearly linked to increases in illness in adults studied in three continents; therefore, it is a reasonable value to choose as a cut-off point for moderate risk. A BMI <16.0 is known to be associated with a markedly increased risk for ill-health, poor physical performance, lethargy and even death; therefore, this cut-off point is a valid extreme limit.

Underweight – The cut-off point of a BMI of 18.5 for underweight in both genders has less experimental validity as a cut-off point for moderate and severe thinness, but is a reasonable value for use pending further comprehensive studies. The proportion of the population with a low BMI that is considered to be a public health problem is closely linked to the resources available for correcting the problem, the stability of the environment and government priorities. About 3–5% of a healthy adult population has a BMI <18.5.

Overweight – A BMI ≥25 signifies overweight; it is a major determinant of many NCDs (e.g. non-insulin-dependent diabetes mellitus, coronary heart disease and stroke), and it increases the risks for several types of cancer, gallbladder disease, musculoskeletal disorders and respiratory symptoms. In some populations, the metabolic consequences of weight gain start at modest levels of overweight.

Obesity – A BMI ≥30 signifies obesity, which is a disease that is largely preventable through lifestyle changes. The costs attributable to obesity are high, not only in terms of premature death and health care, but also in terms of disability and a diminished quality of life.

Cut-off values for public health significance

BMI: body mass index

Source: WHO (1995).

Sources of data

WHO. Global Health Observatory (GHO) data repository. Body mass index (BMI). (http://apps.who.int/gho/data/node.main.BMIANTHROPOMETRY?lang=en).

NCD Risk Factor Collaboration (NCD-RisC). Data downloads. (http://www.ncdrisc.org/data-downloads.html).

Further reading

NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies with 128.9 million participants. Lancet. 2017;Dec 16;390(10113):2627–2642. doi:http://dx.doi.org/10.1016/S0140–6736(17)32129–3.

WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. Technical report series no. 854. Geneva: World Health Organization; 1995 (http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. Obesity and other diet-related chronic diseases list of publications. (http://www.who.int/nutrition/publications/obesity/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target (http://www.who.int/elena/global-targets/en).

Target 7: Halt the rise in diabetes and obesity (http://www.who.int/elena/global-targets/en/#diabetesobesity).

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Adolescent birth rate (per 1,000 women aged 15-19 years)

Adolescent birth rate (per 1000 women aged 15–19 years)

What does this indicator tell us?

The adolescent birth rate, technically known as the age-specific fertility rate, provides a basic measure of reproductive health that focuses on adolescent women as a vulnerable group.

The adolescent birth rate (per 1000 women aged 15–19 years) is included as an intermediate outcome indicator in the core set of indicators for the Global nutrition monitoring framework.

How is this indicator defined?

This indicator is defined as the annual number of births to women aged 15–19 years per 1000 women in that age group. It is also referred to as the age-specific fertility rate for women aged 15–19.

What are the consequences and implications?

There is substantial agreement in the literature that women who become pregnant and give birth early in their reproductive lives are subject to higher risks of complications, or even death, during pregnancy and birth, and their children are also more vulnerable. Therefore, preventing adolescent pregnancy is an important measure to improve maternal health and reduce infant mortality. Furthermore, women who have children at an early age experience a curtailment of their opportunities for socioeconomic improvement, particularly because young mothers are unlikely to keep studying and, if they need to work, may find it especially difficult to combine family and work responsibilities. The adolescent birth rate also provides indirect evidence on access to reproductive health education, since young people, and unmarried adolescent women in particular, often experience difficulties in accessing reproductive health care.

Source of data

WHO. Global Health Observatory (GHO) data repository. Adolescent birth rate. Data by country (http://apps.who.int/gho/data/view.main.GSWCAH31v).

Further reading

WHO. Adolescent pregnancy. In: Fact sheets [website]. Geneva: World Health Organization; 2018 (http://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

Internet resources

United Nations Population Fund (UNFPA). Adolescents pregnancy. (https://www.unfpa.org/adolescent-pregnancy).

WHO. Reproductive health library. Adolescent sexual and reproductive health  (https://extranet.who.int/rhl/topics/adolescent-sexual-and-reproductive-health).

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Malnutrition in women

Moderate and severe thinness, underweight, overweight and obesity

What do these indicators tell us?

The values for body mass index (BMI) are age-independent for adult populations, and are the same for both genders. However, BMI may not correspond to the same degree of fatness in different populations, in part because of different body proportions. The health risks associated with increasing BMI are continuous, and the interpretation of the BMI grading in relation to risk may differ for different populations.

Proportions of underweight in women aged 15–49 years and of overweight in women aged 18 years or more are included as intermediate outcome indicators in the core set of indicators for the Global nutrition monitoring framework. Adult overweight is also included in the NCD global monitoring framework, and in the WHO Global reference list of 100 core health indicators. Underweight in women aged 15–49 years is included as an additional indicator in the WHO Global reference list of 100 core health indicators.

How are these indicators defined?

BMI is a simple index of weight-to-height that is commonly used to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of the height in metres (kg/m²). For example, an adult who weighs 58 kg and has a height of 1.70 m will have a BMI of 20.1, where BMI = 58 kg/(1.70 m ´ 1.70 m) = 20.1. BMI values indicate the following:

What are the consequences and implications?

Moderate and severe thinness – A BMI <17.0 indicates moderate and severe thinness in adult populations. It has been clearly linked to increases in illness in adults studied in three continents; therefore, it is a reasonable value to choose as a cut-off point for moderate risk. A BMI <16.0 is known to be associated with a markedly increased risk for ill-health, poor physical performance, lethargy and even death; therefore, this cut-off point is a valid extreme limit.

Underweight – The cut-off point of a BMI of 18.5 for underweight in both genders has less experimental validity as a cut-off point for moderate and severe thinness, but is a reasonable value for use pending further comprehensive studies. The proportion of the population with a low BMI that is considered to be a public health problem is closely linked to the resources available for correcting the problem, the stability of the environment and government priorities. About 3–5% of a healthy adult population has a BMI <18.5.

Overweight – A BMI ≥25 signifies overweight; it is a major determinant of many NCDs (e.g. non-insulin-dependent diabetes mellitus, coronary heart disease and stroke), and it increases the risks for several types of cancer, gallbladder disease, musculoskeletal disorders and respiratory symptoms. In some populations, the metabolic consequences of weight gain start at modest levels of overweight.

Obesity – A BMI ≥30 signifies obesity, which is a disease that is largely preventable through lifestyle changes. The costs attributable to obesity are high, not only in terms of premature death and health care, but also in terms of disability and a diminished quality of life.

Cut-off values for public health significance

BMI: body mass index

Source: WHO (1995).

Sources of data

WHO. Global Health Observatory (GHO) data repository. Body mass index (BMI). (http://apps.who.int/gho/data/node.main.BMIANTHROPOMETRY?lang=en).

NCD Risk Factor Collaboration (NCD-RisC). Data downloads. (http://www.ncdrisc.org/data-downloads.html).

Further reading

NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies with 128.9 million participants. Lancet. 2017;Dec 16;390(10113):2627–2642. doi:http://dx.doi.org/10.1016/S0140–6736(17)32129–3.

WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. Technical report series no. 854. Geneva: World Health Organization; 1995 (http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. Obesity and other diet-related chronic diseases list of publications. (http://www.who.int/nutrition/publications/obesity/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target (http://www.who.int/elena/global-targets/en).

Target 7: Halt the rise in diabetes and obesity (http://www.who.int/elena/global-targets/en/#diabetesobesity).

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Overweight in school-age children and adolescents

Overweight in school-age children and adolescents

What does this indicator tell us?

This indicator reflects the percentage of school-age children and adolescents aged 5–19 years who are classified as overweight, based on age- and sex-specific values for body mass index (BMI). Overweight indicates excess body weight for a given height from fat, muscle, bone, water or a combination of these factors, whereas obesity is defined as having excess body fat.

Overweight in school-age children and adolescents aged 5–19 years is included as an intermediate outcome indicator in the core set of indicators for the Global nutrition monitoring framework. It is also included in the NCD global monitoring framework, and in the WHO Global reference list of 100 core health indicators.

How is this indicator defined?

Prevalence of overweight in school-age children and adolescents is defined as the percentage of children aged 5–19 years with sex-specific BMI-for-age >+1 SD above the WHO 2007 reference median.

What are the consequences and implications?

The immediate consequences of overweight and obesity in school-age children and adolescents include a greater risk of asthma and cognitive impairment, in addition to the social and economic consequences for the child, for the child’s family and for society. In the long term, overweight and obesity in children increase the risk of health problems later in life, including obesity, diabetes, heart disease, some cancers, respiratory disease, mental health and reproductive disorders. Furthermore, obesity and overweight track over the life-course – an overweight adolescent girl is more likely to become an overweight woman; thus, her baby is likely to have a heavier birth weight.

Source of data

WHO. Global Health Observatory (GHO) data repository. Prevalence of overweight among children and adolescents, BMI > +1 standard deviations above the median, crude.  (crude estimate) (%) (Noncommunicable diseases). Estimates by country, among children aged 5-19 years (http://apps.who.int/gho/data/view.main.BMIPLUS1C05-19v).

Further reading

NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies with 128.9 million participants. Lancet. 2017;Dec 16;390(10113):2627–2642. doi:http://dx.doi.org/10.1016/S0140-6736(17)32129-3.

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. BMI-for-age (5–19 years). Growth reference 5–19 years. (http://www.who.int/growthref/who2007_bmi_for_age/en/).

WHO. NCD global monitoring framework. (http://www.who.int/nmh/global_monitoring_framework/en/).

WHO. Overweight and obesity. Fact sheet (http://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight).

WHO. Commission on ending childhood obesity (http://www.who.int/end-childhood-obesity/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. (http://www.who.int/elena/global-targets/en).

Target 7: Halt the rise in diabetes and obesity (http://www.who.int/elena/global-targets/en/#diabetesobesity).

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Children aged 6–23 months who receive a minimum dietary diversity

Infant and young child feeding

 

To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO and UNICEF recommend:

·   initiation of breastfeeding within the first hour of life;

·   exclusive breastfeeding (i.e. only breast milk with no additional food or drink, not even water);

·   breastfeeding on demand, as often the child wants, day and night; and

·   no use of bottles, teats or pacifiers.

 

The recommendations for feeding infants and young children (6–23 months) include:

·   continued breastfeeding;

·   introduction of solid, semisolid or soft foods at 6 months;

·   appropriate food diversity (at least five food groups per day);

·   appropriate frequency of meals: two to three times a day between 6 and 8 months, increasing to three to four times a day between 9 and 23 months with nutritious snacks offered once or twice a day, as desired;

·   safe preparation of foods; and

·   feeding infants in response to their cues.

 

The caring practice indicators for infant and young child feeding available on the NLIS country profiles include:

• proportion of children aged 0–23 months who were put to the breast within 1 h of birth;
• proportion of infants under 6 months who are exclusively breastfed;
• proportion of infants aged 6–8 months who receive solid, semisolid or soft foods;
• proportion of children aged 6–23 months who receive a minimum dietary diversity; and
• proportion of children aged 6–23 months who receive a minimum acceptable diet.

  

Early initiation of breastfeeding

What does this indicator tell us?

This indicator is the percentage of infants who are put to the breast within 1 hour of birth.

 

How is it defined?

Early initiation of breastfeeding is defined as the proportion of children born in the past 24 months who were put to the breast within 1 hour of birth.

 

What are the consequences and implications?

Breastfeeding improves child health, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

 

Infants under 6 months who are exclusively breastfed

What does this indicator tell us?

This indicator is the percentage of infants aged 0–5 months who are exclusively breastfed.

 

How is it defined?

It is the proportion of infants aged 0–5 months who are fed exclusively on breast milk and no other food or drink, including water. The infant is however, allowed to receive ORS and drops or syrups containing vitamins, minerals and medicine.

 

What are the consequences and implications?

Exclusive breastfeeding is an unequalled way of providing the ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process, with important health benefits for mothers. An expert review of evidence showed that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants.

Breast milk is the natural first food for infants. It provides all the energy and nutrients that the infant needs for the first months of life. It continues to provide up to one half or more of a child’s nutritional needs during the second half of the first year and up to one third during the second year of life.

Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment.

 

Infants aged 6–8 months who receive solid, semisolid or soft foods

What does this indicator tell us?

The indicator is the percentage of infants  between 6-8 months of age who received solid, semisolid or soft foods. WHO recommends starting complementary feeding at 6 months of age.

 

How is it defined?

It is defined as the proportion of infants aged 6–8 months who receive solid, semisolid or soft foods during the previous day.

 

What are the consequences and implications?

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. The transition from exclusive breastfeeding to family foods, referred to as ‘complementary feeding’, typically occurs between 6 and 18–24 months of age. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

 

Children aged 6–23 months who receive a minimum dietary diversity

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum dietary diversity.

Proportion of children aged 6-23 months who receive a minimum dietary diversity is included as an interim process indicator in the core set of indicators for the Global Nutrition Monitoring Framework while the original indicator “Minimum Acceptable Diet” is being further developed and validated under the leadership of the WHO-UNICEF Technical Expert Advisory group on nutrition Monitoring (TEAM). In June 2017, TEAM also recommended to revise the MDD indicator as defined by WHO (2008) to make it feasible and meaningful for Member State reporting. The revision concerned adding “breast milk” as an 8th food group and shifting the criterion for MDD accordingly, from 4 of 7 groups to 5 of 8 groups.

 

How is it defined?

As recommended by the TEAM in June 2017, dietary diversity is present when the diet contained five or more of the following food groups:

·         breast milk;

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

 

Children aged 6–23 months who receive a minimum acceptable diet

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum acceptable diet.

Proportion of children aged 6-23 months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

 

How is it defined?

The composite indicator of a minimum acceptable diet is calculated from:

·    the proportion of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day and

• the proportion of non-breastfed children aged 6–23 months who received at least two milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day.

Dietary diversity is present when the diet contained five or more of the following food groups:

·         breast milk;

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

The minimum daily meal frequency is defined as:

• twice for breastfed infants aged 6–8 months,
• three times for breastfed children aged 9–23 months and
• four times for non-breastfed children aged 6–23 months.

 

What are the consequences and implications?

A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6–23 months. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality.

 

Source of all infant and young child feeding indicators

UNICEF. UNICEF Data: Monitoring the Situation of Children and Women. https://data.unicef.org.

 

Further reading

WHO. Infant and young child feeding list of publications. http://www.who.int/nutrition/publications/infantfeeding/en/index.html.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA):

·         Breastfeeding: early initiation. http://www.who.int/entity/elena/titles/early_breastfeeding/en/index.html.

·         Breastfeeding: exclusive breastfeeding. http://www.who.int/entity/elena/titles/exclusive_breastfeeding/en/index.html.

·         Breastfeeding: continued breastfeeding. http://www.who.int/entity/elena/titles/continued_breastfeeding/en/index.html.

·         Complementary feeding. http://www.who.int/entity/elena/titles/complementary_feeding/en/index.html.

WHO. WHO Global Data Bank on Infant and Young Child Feeding. http://www.who.int/nutrition/databases/infantfeeding/en/index.html.

WHO/UNICEF. Global Nutrition Monitoring Framework. Operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017. http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/.

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% Population using improved drinking water sources

Improved sanitation facilities and drinking-water sources

What do these indicators tell us?

These indicators are the percentage of the population with access to improved sanitation facilities and access to an improved drinking-water source.

The two indicators – “proportion of population using safely managed sanitation services” and “proportion of population using safely managed drinking services” – are included as intermediate outcome indicators in the core set of indicators for the Global nutrition monitoring framework.

How are these indicators defined?

Improved drinking-water sources are defined as those that are likely to be protected from outside contamination, and from faecal matter in particular. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Unimproved water sources include unprotected wells, unprotected springs, surface water (e.g. river, dam or lake), vendor-provided water, bottled water (unless water for other uses is available from an improved source) and tanker truck–provided water. According to the WHO/UNICEF joint monitoring programme, basic drinking-water services are defined as drinking water from an improved source, provided that collection time is not more than 30 minutes for a roundtrip, including queuing. Basic sanitation services are defined as use of improved sanitation facilities that are not shared with other households. This is identical to the “improved but not shared” category used in previous reports.

Improved sanitation facilities are defined as those that hygienically separate human waste from human contact. Improved sanitation includes flush or pour-flush to piped sewer system, septic tank pit latrines, ventilated-improved pit latrines, or pit latrines with slab or composting toilets. Shared or public-use sanitation facilities are not considered to be improved. Also, flush or pour-flush to elsewhere, pit latrines without slabs or open pits, bucket latrines, hanging latrines or open defecation are not considered to be improved sanitation.

What are the consequences and implications?

Access to safe drinking water and improved sanitation are fundamental needs and human rights that are vital for the dignity and health of all people. The health and economic benefits of a safe water supply to households and individuals (especially children) are well documented.

Source of data

WHO. Global Health Observatory (GHO) data repository.

·         Basic and safely managed drinking water services. Data by country. (http://apps.who.int/gho/data/node.main.WSHWATER?lang=en).

·         Basic and safely managed sanitation services. Data by country. (http://apps.who.int/gho/data/node.main.WSHSANITATION?lang=en).

Further reading

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

Internet resources

WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) (https://washdata.org).

WHO. Water sanitation hygiene (http://www.who.int/water_sanitation_health/en/).

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Population using an improved sanitation facility and improved drinking water sources

Improved sanitation facilities and drinking-water sources

What do these indicators tell us?

These indicators are the percentage of the population with access to improved sanitation facilities and access to an improved drinking-water source.

The two indicators – “proportion of population using safely managed sanitation services” and “proportion of population using safely managed drinking services” – are included as intermediate outcome indicators in the core set of indicators for the Global nutrition monitoring framework.

How are these indicators defined?

Improved drinking-water sources are defined as those that are likely to be protected from outside contamination, and from faecal matter in particular. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Unimproved water sources include unprotected wells, unprotected springs, surface water (e.g. river, dam or lake), vendor-provided water, bottled water (unless water for other uses is available from an improved source) and tanker truck–provided water. According to the WHO/UNICEF joint monitoring programme, basic drinking-water services are defined as drinking water from an improved source, provided that collection time is not more than 30 minutes for a roundtrip, including queuing. Basic sanitation services are defined as use of improved sanitation facilities that are not shared with other households. This is identical to the “improved but not shared” category used in previous reports.

Improved sanitation facilities are defined as those that hygienically separate human waste from human contact. Improved sanitation includes flush or pour-flush to piped sewer system, septic tank pit latrines, ventilated-improved pit latrines, or pit latrines with slab or composting toilets. Shared or public-use sanitation facilities are not considered to be improved. Also, flush or pour-flush to elsewhere, pit latrines without slabs or open pits, bucket latrines, hanging latrines or open defecation are not considered to be improved sanitation.

What are the consequences and implications?

Access to safe drinking water and improved sanitation are fundamental needs and human rights that are vital for the dignity and health of all people. The health and economic benefits of a safe water supply to households and individuals (especially children) are well documented.

Source of data

WHO. Global Health Observatory (GHO) data repository.

·         Basic and safely managed drinking water services. Data by country. (http://apps.who.int/gho/data/node.main.WSHWATER?lang=en).

·         Basic and safely managed sanitation services. Data by country. (http://apps.who.int/gho/data/node.main.WSHSANITATION?lang=en).

Further reading

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

Internet resources

WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) (https://washdata.org).

WHO. Water sanitation hygiene (http://www.who.int/water_sanitation_health/en/).

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Antenatal iron supplementation

Antenatal iron supplementation

What does this indicator tell us?

This indicator reflects the percentage of women who consumed any iron-containing supplements during their current or previous pregnancy within the past 2 years. It provides information about the quality and coverage of perinatal medical services.

Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care, to reduce the risk of low birth weight, maternal anaemia and iron deficiency. It is suggested that the supplement contains 30–60 mg of iron, with the higher dose preferred in settings where anaemia in pregnant women is a severe public health problem (≥40%), along with 400 µg of folic acid. Daily supplementation throughout pregnancy, beginning as early as possible after conception, is recommended in all settings. Despite its proven efficacy and wide inclusion in antenatal care programmes, the use of iron and folic acid supplementation has been limited in programme settings. Possible reasons for this include a lack of compliance, concerns about the safety of the intervention among women with an adequate iron intake, and variable availability of the supplements at community level. Intermittent use of iron and folic acid supplements by non-anaemic women is a recommended alternative to prevent anaemia and improve gestational outcomes in areas where the prevalence of anaemia among pregnant women is lower than 20%. The suggested dose is 120 mg elemental iron and 2800 µg (2.8 mg) folic acid provided weekly throughout the pregnancy, beginning as early as possible after conception.

This indicator is included as a process indicator in the core set of indicators for the Global nutrition monitoring framework.

How is this indicator defined?

This indicator is defined as the proportion of women who consumed any iron-containing supplements during their current or previous pregnancy within the past 2 years. Data can be reported on any iron-containing supplement, including iron and folic acid tablets, multiple micronutrient tablets or powders, or iron-only tablets (which will vary, depending on the country policy).

What are the consequences and implications?

Improving the intake of iron and folic acid by women of reproductive age could improve pregnancy outcomes, and improve maternal and infant health. Iron and folic acid supplementation is used to improve the iron and folate status of women before and during pregnancy, in communities where food-based strategies are not yet fully implemented or effective. Folic acid supplementation (with or without iron) provided before conception and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects.

Anaemia during pregnancy places women at risk for poor pregnancy outcomes, including maternal mortality; it also increases the risks for perinatal mortality, premature birth and low birth weight. Infants born to anaemic mothers have less than one half the normal iron reserves. Morbidity from infectious diseases is increased in iron-deficient populations, owing to the adverse effect of iron deficiency on the immune system. Iron deficiency is also associated with reduced work capacity and reduced neurocognitive development.

Source of data

Demographic and health surveys (DHS) program STATcompiler (http://www.statcompiler.com/).

Further reading

WHO. Developing and validating an iron and folic acid supplementation indicator for tracking progress towards global nutrition monitoring framework targets. Final report - June 2018. Geneva: World Health Organization; 2018 (https://www.who.int/nutrition/publications/ironfolic-indicator-GNMF/en/).

WHO. Weekly iron and folic acid supplementation as an anaemia-prevention strategy in women and adolescent girls. Lessons learnt from implementation of programmes among nonpregnant women of reproductive age. Geneva: World Health Organization; 2018 (https://www.who.int/nutrition/publications/micronutrients/WIFS-anaemia-prevention-womenadolescent-girls/en/).

WHO. Weekly iron-folic acid supplementation (WIFs) in women of reproductive age: its role in promoting optimal maternal and child health. Geneva: World Health Organization; 2009 (http://www.who.int/nutrition/publications/micronutrients/weekly_iron_folicacid.pdf).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

Internet resources

WHO. Global targets 2025 to improve maternal, infant and young child nutrition. (http://who.int/nutrition/global-target-2025/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA)

• Daily iron and folic acid daily supplementation during pregnancy (http://www.who.int/entity/elena/titles/daily_iron_pregnancy/en).
• Intermittent iron and folic supplementation in non-anaemic pregnant women (http://www.who.int/elena/titles/guidance_summaries/intermittent_iron_pregnancy/en/)

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Births in baby-friendly facilities

Births in baby-friendly facilities

What does this indicator tell us?

The Baby-friendly Hospital Initiative (BFHI), launched by WHO and UNICEF in 1991, is part of a global effort to protect, promote and support optimal breastfeeding practices. To be designated as “baby-friendly”, facilities must implement the Ten steps to successful breastfeeding to protect, promote and support breastfeeding. This indicator reflects the proportion of babies born in facilities that have been designated as baby-friendly.

The indicator “Proportion of births in baby-friendly facilities” is included as a process indicator in the core set of indicators for the Global nutrition monitoring framework.

How is this indicator defined?

This indicator is defined as the proportion of babies born in facilities designated as baby-friendly in a calendar year. To be counted as currently baby-friendly, the facility must have been designated within the past 5 years or have been reassessed within that time frame. Facilities may be designed as baby-friendly if they meet the minimum global criteria, which includes adherence to:

·         the Ten steps for successful breastfeeding – these steps include having a breastfeeding policy that is routinely communicated to staff, having staff trained on policy implementation, informing pregnant women on the benefits and management of breastfeeding, and promoting early initiation of breastfeeding; and

·         the International Code of Marketing of Breast-milk Substitutes – the Code restricts the distribution of free infant formula and promotional materials from infant formula companies.

What are the consequences and implications?

Research has found that adherence to BFHI’s Ten steps leads to improved breastfeeding outcomes, which positively impact the health of both the mother and child. The more of the Ten steps that the mother experiences, the better her success with breastfeeding. Improved breastfeeding practices worldwide could save the lives of more than 800 000 children every year.

Source of data

WHO. National implementation of the Baby-friendly Hospital Initiative 2017. Geneva: World Health Organization; 2017 (http://who.int/nutrition/publications/infantfeeding/bfhi-national-implementation2017/en/).

Further reading

WHO, UNICEF. Global nutrition targets 2025: breastfeeding policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_breastfeeding/en/).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

Internet resources

WHO. Baby-friendly Hospital Initiative. (http://www.who.int/nutrition/bfhi/en/).

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Implementation of the Baby-friendly Hospital Initiative. (http://www.who.int/elena/titles/implementation_bfhi/en/).

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Availability of national-level provision for breastfeeding counselling services in public health and/or nutrition programmes

Availability of national-level provision for breastfeeding counselling services in public health and/or nutrition programmes

What does this indicator tell us?

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. Optimal practices include early initiation of breastfeeding within 1 hour and exclusive breastfeeding for 6 months, followed by appropriate complementary with continued breastfeeding for 2 years or beyond. Although it is a natural act, breastfeeding is also a learnt behaviour. Almost all mothers can breastfeed provided they have accurate information, and have support within their families and communities, and from the health care system. Mothers should also have access to skilled practical help from, for example, trained health workers, lay and peer counsellors, and certified lactation consultants. These professionals can help to build a mother’s confidence, improve feeding technique, and prevent or resolve breastfeeding problems.

This indicator has been established as an interim indicator, while the WHO-UNICEF Technical Expert Advisory group for nutrition Monitoring (TEAM) is further developing and validating the indicator “proportion of mothers receiving breastfeeding counselling, support or messages” – a process indicator in the core set of indicators for the Global nutrition monitoring framework.

How is this indicator defined?

This indicator is defined as availability of a national programme that includes provision for delivering breastfeeding counselling services to mothers of infants aged 0–23 months, through health systems or other community-based platforms.

What are the consequences and implications?

Counselling and informational support on optimal breastfeeding practices for mothers improves initiation and duration of breastfeeding, which has many health benefits for both the mother and infant. Breast milk contains all the nutrients an infant needs in the first 6 months of life. Also, breastfeeding protects against diarrhoea and common childhood illnesses such as pneumonia, and it may have longer term health benefits for the mother and child, such as reducing the risk of overweight and obesity in childhood and adolescence. Breastfeeding has also been associated with higher IQ in children. Improved breastfeeding practices worldwide could save the lives of more than 800 000 children every year.

Sources of data

WHO. Global nutrition policy review. What does it take to scale-up nutrition action? Geneva: World Health Organization; 2013 (www.who.int/nutrition/publications/policies/global_nut_policyreview/en/).

WHO. Global nutrition policy review 2016-2017. Country progress in creating enabling policy environments for promoting healthy diets and nutrition. Geneva: World Health Organization; 2018 (www.who.int/nutrition/publications/policies/global_nut_policyreview/en/).

WHO. Global database on the implementation of nutrition action (GINA) (https://extranet.who.int/nutrition/gina/).

International Baby Food Action Network (IBFAN). World breastfeeding trends initiative. (http://worldbreastfeedingtrends.org).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

Further reading

WHO, UNICEF. Global strategy for infant and young child feeding. Geneva: World Health Organization; 2003 (http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/).

WHO, UNICEF. Global nutrition targets 2025: Breastfeeding policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_breastfeeding/en/).

Internet resources

WHO. e-Library of Evidence for Nutrition Actions (eLENA)

·         Breastfeeding education for increased breastfeeding duration (http://www.who.int/elena/titles/breastfeeding_education/en/).

·         Implementation of the Baby-friendly Hospital Initiative (http://www.who.int/elena/titles/implementation_bfhi/en/).

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Density of nutrition professionals

Density of trained nutrition professionals per 100 000 population

What does the indicator tell us?

This indicator reflects the capacity of a country to design and implement nutrition policies and programmes effectively.

It focuses on individuals who are trained to pursue a professional career in nutrition, described in most countries as dietitians or nutritionists (including nutrition scientists, nutritional epidemiologists and public health nutritionists). These individuals are trained sufficiently in nutrition practice to demonstrate defined competencies, and to meet the certification or registration requirements of national or global nutrition or dietetics professional organizations. This training, at universities or other tertiary or higher education institutions, may occur at bachelor, post-graduate certificate or diploma, masters or doctoral degree levels.

Only in some countries do dietitians and nutritionists complete the same training and perform the same functions. Similarly, professional registration or accreditation of dietitians and nutritionists only occurs in some countries, and where it does occur it may be joint or separate. Countries are encouraged to implement the professional registration or accreditation of dietitians and nutritionists, to provide a guarantee of appropriate training and professional competence.

The indicator “number of trained nutrition professionals per 100 000 population” is included as a policy environment and capacity indicator in the core set of indicators for the Global nutrition monitoring framework.

How is this indicator defined?

This indicator is defined as the number of trained nutrition professionals per 100 000 population in the country in a specified year.

What are the consequences and implications?

Trained nutrition professionals work at facilities including health facilities and at population and community levels; they may influence nutrition policies and design as well as the implementation of nutrition intervention programmes at various levels. They also play an important role in training other health and non-health cadres to plan and deliver nutrition interventions in various settings. The requirement for a “trained nutrition professionals” indicator is based on recognition that the availability of a sufficient workforce with appropriate training in nutrition within a country will lead to better outcomes for country-specific nutrition and health concerns. Validation of the indicator has shown that it can predict several maternal, infant and young child nutrition outcomes.

Source of data

WHO. Global nutrition policy review 2016-2017. Country progress in creating enabling policy environments for promoting healthy diets and nutrition. Geneva: World Health Organization; 2018 (www.who.int/nutrition/publications/policies/global_nut_policyreview/en/).

Further reading

Hughes R, Shrimpton R, Recine E, Margetts B. A competency framework for global public health nutrition workforce development: a background paper. World Public Health Nutrition Association; 2011 (http://www.wphna.org/htdocs/downloadsapr2012/12–03%20WPHNA%20Draft%20competency%20standards%20report.pdf).

Ellahi B, Annan R, Sarkar S, Amuna P, Jackson AA. Building systemic capacity for nutrition: training towards a professionalised workforce for Africa. Proc Nutr Soc. 2015;74(4):496–504.

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

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Monitoring and enforcement of the International Code on Marketing of Breast-milk Substitutes

Monitoring and enforcement of the International Code of Marketing of Breast-milk Substitutes

What does this indicator tell us?

This indicates whether a government has adopted legislation to monitor and enforce the International Code of Marketing of Breast-milk Substitutes (the Code) – an international health policy framework that was adopted by the World Health Assembly in 1981 – and its subsequent related resolutions.

The number of countries with legislation or regulations that fully implement the Code, and the subsequent relevant resolutions adopted by the Health Assembly, is included as a policy environment and capacity indicator in the Global nutrition monitoring framework. It is also included as an additional indicator in the WHO Global reference list of 100 core health indicators.

How is this indicator defined?

This indicator is defined on the basis of whether a government has adopted legislation for the effective national implementation and monitoring of the Code, which is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats. The Code aims to contribute “to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution” (Article 1).

What are the consequences and implications?

The improper marketing and promotion of food products that compete with breastfeeding often negatively affect the choices and ability of a mother to feed her infant optimally, by discouraging the practice of breastfeeding. The Code was formulated in response to the realization that such marketing resulted in poor infant feeding practices, which in turn negatively affect the growth, health and development of children, and are a major cause of mortality in infants and young children. The Code seeks to promote the practice of breastfeeding and ensure that substitutes, if necessary, are used safely.

Worldwide, breastfeeding practices are not yet optimal, both in developing and developed countries, especially regarding exclusive breastfeeding under 6 months of age. In addition to the risks posed by the lack of breast milk’s protective qualities, breast-milk substitutes and feeding bottles are associated with a high risk of contamination, which can lead to life-threatening infections in young infants. Infant formula is not a sterile product, and it may carry infectious agents that can cause fatal illnesses. Artificial feeding is expensive, it requires clean water, the ability of the mother or caregiver to read and comply with mixing instructions, and a minimum standard of overall household hygiene. These factors are not present in many of the world’s households.

Source of data

WHO, UNICEF, International Baby Food Action Network (IBFAN). Marketing of breast-milk substitutes: national implementation of the international code: status report 2018. Geneva: World Health Organization; 2018 (http://www.who.int/nutrition/publications/infantfeeding/code_report2018/en/).

Further reading

WHO, UNICEF, IBFAN. Marketing of breast-milk substitutes: national implementation of the international code: status report 2016. Geneva: World Health Organization; 2016 (http://www.who.int/nutrition/publications/infantfeeding/code_report2016/en/).

WHO. The international code of marketing of breast-milk substitutes: frequently asked questions, 2017 update. Geneva: World Health Organization; 2018 (http://who.int/nutrition/publications/infantfeeding/breastmilk-substitutes-FAQ2017/en/).

WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).

WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).

Internet resources

WHO. e-Library of Evidence for Nutrition Actions (eLENA). Regulation of marketing breast-milk substitutes. (http://www.who.int/elena/titles/regulation_breast-milk_substitutes/en/).

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