Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694842026321.pdf (Pakistan)
Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Khyber Pakhtunkhwa Nutrition Policy Guidance Notes Planning and Development Department Government of Khyber Pakhtunkhwa September, 2013 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Nutrition Policy Guidance Note Khyber Pakhtunkhwa September, 2013 Planning and Development Department Government of Khyber Pakhtunkhwa Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Nutrition Policy Guidance Note-Khyber Pakhtunkhwa T A B L E O F C O N T E N T S Introduction ........................................................................................................................................... 1 Presentation of primary data on malnutrition ........................................................................... 2 The case for investment in nutrition .............................................................................................. 4 Sector by sector relationships with malnutrition and potential nutrition improvement .......................................................................................................................................... 9 Water, Sanitation and Hygiene (WASH) ........................................................................................ 10 Food Security ............................................................................................................................... 12 Utilization of Health Services ........................................................................................................ 13 Infant and Young Child Feeding Practices (IYCF) ............................................................................ 14 Education of Girls ......................................................................................................................... 15 Poverty Alleviation and Social Protection ..................................................................................... 17 Conclusions and Recommendations ................................................................................................... 19 Intervention-related Recommendations ....................................................................................... 19 Coordination and Advocacy .......................................................................................................... 21 Attention to Cross-Cutting Issues .................................................................................................. 22 References ......................................................................................................................................... 23 Appendix-1: Overweight and Obesity in Pakistan ................................................................... 25 Appendix-2: Update on Process in Khyber Pakhtunkhwa for Development of Nutrition Policy and Multisectoral Integrated Strategy ........................................................ 26 Figure 1: Comparison of Stunting Rates ................................................................................................................. 3 Figure 2: Malnutrition Reduces Productivity: 3 Pathways ...................................................................................... 4 Figure 3: Stunting Rates by Age (Pakistan) ............................................................................................................. 6 Figure 4: Nutrition throughout the Life Cycle ......................................................................................................... 7 Figure 5: Determinants of Child Nutrition ............................................................................................................ 10 Figure 6: Stunting by Soap Availability for Handwashing ..................................................................................... 11 Figure 7: Anemia among children practicing open defecation .............................................................................. 11 Figure 8: Anemia among children not practicing open defecation ....................................................................... 12 Figure 9: Food Security and Stunting.................................................................................................................... 13 Figure 10: Gender Equity Trends in School Enrollment in KP ................................................................................ 16 Figure 11: Mother’s Education and Child Stunting ............................................................................................... 17 Figure 12: Child Stunting and Wasting by Wealth Quintile ................................................................................... 18 Table 1: Malnutrition in KP and Consequences ...................................................................................................... 5 Table 2: Type of practitioner consulted for childhood diarrhea ........................................................................... 14 Table 3: IYCF Practices in KP ................................................................................................................................. 14 Table 4: BMI Status by Education, Income and Anemia Indicators ....................................................................... 25 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Introduction Pakistani women and children suffer from some of the highest rates of malnutrition in the world with a national nutritional stunting prevalence among children under five of 43.7%1 2 Pakistan also has the second highest number of severely wasted children next to India.
The magnitude of the country’s nutrition problem is reflected by the fact that half of the world’s malnourished women and children, and an estimated 78% of the world’s wasted children live in Bangladesh, India and Pakistan (Gross R, Webb P 2006.)
Recognizing the implications of such high levels of malnutrition for economic and human development (discussed below) and for efforts to achieve Millennium Development Goals3, the Government of KP and its partners have decided to undertake a multisectoral nutrition review involving representatives of those key development sectors which, collectively, have considerable potential for reducing malnutrition significantly in these provinces.
The review is designed to assess provincial malnutrition levels, identify sectoral programs which have been associated with malnutrition reductions, and to begin identifying possible roles for these sectors in a collective effort to reduce malnutrition in the province.

Also made explicit in the reviews are the benefits likely to accrue to each of the sectors from improved nutrition in the province.
Multisectoral Nutrition in Peru  After a decade of little change in stunting prevalence, the Office of the Prime Minister with donor agency encouragement, issued directives, and itself facilitated horizontal integration among Ministries of Education, Health, Women and Social Development and Finance and Economics.

 A conditional cash transfer program (JUNTOS) was also coordinated among these ministries.
 Simultaneously, the Child Nutrition Initiative: a coalition of government, international agencies, NGOs and civil society organizations assumed a primary role in advocacy In 2006, the Child Nutrition Initiative succeeded in getting 10 presidential candidates to sign a commitment to reduce chronic malnutrition in children under 5 by 5 percentage points in 5 years (“5 by 5 by 5”)   As a result, Peru reduced stunting: from 22.9% (rural 40.1%) in 2005 to 17.9% (rural 31.3%) in 2010 thereby achieving its target of a 5 percentage point decrease in 5 years 1 All data is from the Pakistan National Nutrition Survey (NSS), 2011 unless otherwise indicated.
The 2011 survey is the first to provide representative data for each of the provinces.

2 By comparison, India = 48%; Nepal = 45%; Bangladesh = 43%; D.R.

Congo = 43%; Sri Lanka = 17% 3 Nutrition is associated with six of the MDGs: Goal 1 relating to the eradication of poverty and hunger, Goal 2 relating to universal primary education, Goal 3 relating to gender equality, Goal 4 relating to child mortality, Goal 5 relating to maternal health, and Goal 6 relating to infectious disease.
Page 1 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Presentation of primary data on malnutrition Despite multiple problems faced by the province: the political and security-related crises, the immigration of large numbers of Afghan nationals, and the 2010 flood, the provincial government has expressed commitment to initiate reforms and adopted a medium term Comprehensive Development Strategy (CDS) in 2010 linked with MDG targets.
Additionally the province has put in place social safety net programs such as the Bacha Khan Poverty Alleviation Program which aims to provide micro credit on easy terms to particularly low income households throughout the province.

Anthropometric (weight and height) measurements of children Weight and height measurements are valuable indicators of the health (present and future) of a young child and, in turn, of capacity and potential.

They are not simply about the child’s size.


Stunting means that a child is too short for his/her age This indicates “chronic” malnutrition, accumulated over long period of time.

Stunting generally occurs before age 2 and is largely irreversible.

Wasting means that a child has a weight that is too low for his/her height This indicates “acute” malnutrition, often the result of significant food shortage and/or severe disease that has affected the child in a short period of time.
This measure, regularly used in emergencies, also can be measured using mid-upper arm circumference (MUAC) tapes.

Underweight means that a child has a weight that is too low of his/her age This can be a reflection of acute and/or chronic malnutrition and is an indicator used to assess progress on Millennium Development Goal #1.

The nutrition challenge faced by the province, however, is substantial.

Nearly half of the province’s children under age 5 are nutritionally stunted (47.8%)4.
The prevalence of underweight children is 24.1%, while wasting prevalence is 17.3%.5 These figures have not changed significantly in the past decade.

See Figure 1 below which compares stunting in KP with national and regional figures.

4 The only provinces/regions which are higher are FATA, Balochistan and GB.

Stunting prevalence for the country as a whole is 43.7%.
5 It should be noted that while high rates of wasting may in some contexts reflect a rapid improvement in children’s nutritional status where height is increasing more rapidly than weight (Stifel et al, 1999; Glewwe et al, 2002), this is unlikely to be the case in KP where stunting levels have not been decreasing.
Page 2 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 1: Comparison of Stunting Rates Comparison of Stunting Rates 48 44 48 45 43 17 60 50 40 30 20 10 0 KP Pakistan India Nepal Bangladesh Sri Lanka Unlike many other areas in South Asia, there are no significant differences in the nutritional status of young girls and boys in KP.

Problems emerge for females however in adolescence and adulthood.
Only 57.5% of women in KP have body mass index which is normal, while 9.0% are underweight and 33.5% are overweight or obese.

(Note: Because of the surprisingly high prevalence of overweight and obesity, some country level analysis has been carried out and is presented in the Appendix.)

Finally, micronutrient deficiencies in KP are serious.
Vitamin A deficiency, which jeopardizes the maintenance of primary functions including eyesight, and seriously reduces immune function leaving the body more susceptible to infection, affects 66% of women and 69% of children.

Only Balochistan and GB have higher prevalence rates.

Moderate and severe anemia, resulting in part from iron deficiency, and reducing the flow of oxygen from the lungs to the rest of the body, affects 36% of women in the province and 73% of children.
Iodine deficiency disorders (IDD) are the single most common cause of preventable mental retardation and brain damage with even mild IDD associated with cognitive loss.

In KP, 26% of school age children suffer from iodine deficiency disorders, lower than other provinces/regions but still unacceptably high.

The provincial government is addressing this problem aggressively through salt iodization which presently covers 64% of KP families.
High levels of malnutrition are consistent with high rates of infant and maternal mortality.

The infant mortality rate in KP is 76 per 1000 live births, higher than the national average.

Maternal mortality in the province is 275 maternal deaths per 100,000 live births, higher than that of India, Sri Lanka and Yemen.
Page 3 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa The case for investment in nutrition Figure 2: Malnutrition Reduces Productivity: 3 Pathways Malnutrition Reduces Productivity: 3 Pathways The case for investment in nutrition Overall loss to the economy of 2.7 to 4.1% of GDP annually6 Malnutrition in KP places constraints on economic and social development in the province through three primary pathways as depicted in Figure 2 above:  Direct losses in productivity from impaired physical status – Nutritional status has a clear relationship with productivity (Behrman and Rosenzweig, 2001.)
A 1% loss in adult height resulting from childhood stunting is associated with a 1.4% loss in productivity (Hunt J, 2005.)

Anemia also has a direct effect on the productivity of adults in physically demanding occupations.

Eliminating anemia can increase adult productivity from 5-17% (Horton S et al, 2003.)

Indirect losses from poor cognitive function, leading to decreased active learning capacity and deficits in school benefits.
Low birth weight resulting from fetal malnutrition can reduce a person’s IQ by 5 percentage points, stunting can reduce IQ by 5-11 points, and iodine deficiency by 10-15 points.

Malnutrition has been found to reduce the likelihood that children will be enrolled in school and reduces the learning capacity of those who are enrolled.

There are clear and direct relationships between school performance and subsequent earnings (Grantham-McGregor et al, 1999.)
 6 “Economic Costs of Malnutrition”, paper prepared for DFID by Institute of Public Policy, Beaconhouse National University, Lahore, Social Policy and Development Centre, Karachi and Macroeconomic Insights, Islamabad, June 2012, unpublished.

Page 4 of 28 Cost inefficiencies (e.g.


illness, deaths) Direct links: decreased physical productivity Indirect links: impaired cognitive development, schooling and productivity Nutrition Policy Guidance Note-Khyber Pakhtunkhwa  Losses emanating from increased health costs resulting when malnutrition reduces immune response to infection.

Malnourished children with poor schooling outcomes are also likely to repeat years more often increasing education costs.
Such costs fall largely on governments which are responsible for financing health and education for those unable to pay.

The consequences of malnutrition are put in perspective for KP in Table 1 below.
Table 1: Malnutrition in KP and Consequences Form of Malnutrition Prevalence in KP Consequence Stunting (under 5) 47.8% Reduction of 5-11 IQ points per child7 Wasting (under 5) Iodine deficiency disorder (school age children) Moderate = 8.6%; Severe = 8.7% Odds ratio of mortality: moderate wasting = 3.0; severe wasting 9.48 26.0% Reduction of 10-15 IQ points per child Anaemia (under 5) 47.3% Reduced adult productivity by 5-17% Loss of up to 25 IQ points in children under 2 Vitamin A deficiency (under 5) 68.5% Reduced immunity to disease by 23% The “first 1000 days,” i.e.
the period from conception to two years of age (minus 9 months to plus 24 months) is well recognized as the critical window of opportunity to address malnutrition.

impact on The supporting evidence is clear.

For infants and children under the age of two who survive, the consequences of undernutrition are particularly severe, often irreversible, and have profound effects over their lifetimes.

During pregnancy, undernutrition can have a the healthy growth and devastating development of a child.
(See the “Utilization of Health Services” section below for information on Pakistan’s prevalence of low birth weight, among the highest in the world.)

Malnutrition during the fetal period increases significantly the risk of dying in infancy as well as the risk of developing non-communicable diseases such as diabetes in adulthood.

Those who survive are likely to face lifelong cognitive and physical deficits and chronic health problems.
For children under the age of two, undernutrition can be life-threatening.

It can weaken a child’s immune Nutrition and Wage Rates in Guatemala In Guatemala, individuals who were well nourished before age 3 had, as adults, wage rates 34-47% higher than those were who undernourished as young children.

Hoddinott et al, 2008 7 Figures on consequences are taken from The Lancet Series, 2008.

8 i.e.
8 i.e.

a severely wasted child has a 9.4 times greater risk of dying before the age of 5 than a child who is not wasted (The Lancet Series, 2008.)

Page 5 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa system and make him or her more susceptible to dying from common illnesses such as pneumonia or diarrhea.
Figure 3 below, for Pakistan as a whole, indicates clearly that stunting, which is already significant in the under 6 month period because of fetal malnutrition and low birthweight, increases steadily until two years of age after which it levels off and then decreases.
Figure 3: Stunting Rates by Age (Pakistan) 55 52 48 38 60 50 40 30 20 10 0 29 24 <6 months 6-11 months 12-23 months 24-35 months 36-47 months 48-59 months Finally, addressing malnutrition in the first 1000 days and the necessity of healthy pregnancies depends importantly on the nutritional wellbeing of adolescent girls.

International evidence now suggests that pre-pregnancy nutritional status and iron stores have a greater effect on pregnancy outcomes than anything taking place during the pregnancy period.
(See Figure 4 below on nutrition and the life cycle.)

Page 6 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 4: Nutrition throughout the Life Cycle In combination these consequences of malnutrition have adverse effects on national social and economic development, and reinforce vicious cycles of malnutrition and poverty.

At the same time, interventions to address malnutrition are remarkably cost effective.
The box below indicates that five of the ten most cost-effective means of advancing global welfare, as determined by leading economists in the Copenhagen Consensus, are nutrition-related.9 9 The 2012 Copenhagen Consensus, following the model of comparable efforts in 2004 and 2008, called together a group of internationally renowned economists, among them four Nobel laureates, to respond to the question: “If we had an extra $75 billion to put to good use, which problems would we solve first?” The experts evaluated a broad array of potential investments capable of addressing major global challenges based on highly quantified background papers, and then ranked these approaches according to cost-effectiveness criteria.
Page 7 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Copenhagen Consensus – Top 10 investments for advancing global welfare 1.

Micronutrient supplements (vitamin A & zinc) – Malnutrition 2.

The Doha development agenda – Trade 3.

Micronutrient fortification (iron and iodine) – Malnutrition 4.

Expanded immunization coverage for children – Diseases 5.

Agricultural R&D on micronutrients – Malnutrition 6.

Deworming and nutrition programs at school – Malnutrition 7.
Lowering the price of schooling – Education 8.

Increase and improve girls’ schooling – Women 9.

Community-based nutrition promotion – Malnutrition 10.

Provide support for women’s reproductive role - Women Page 8 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Sector by sector relationships with malnutrition and potential nutrition improvement Figure 5 below presents the classic UNICEF conceptual framework of the determinants of child malnutrition.
As can be seen, malnutrition is the direct result of inadequate food/nutrient intake and infectious disease, the latter resulting in an inability of the body to properly absorb the nutrients consumed.
Inadequate food and nutrient intake, in turn, is, in part the result of inadequate access to food (food insecurity), while “disease” often results from some combination of inadequate provision of health services and poor environment (water, sanitation and hygiene practices or WASH.) Both inadequate food intake and poor health are importantly affected by deleterious maternal and child care practices (an underlying determinant of malnutrition along with food insecurity and inadequate provision of WASH and health services.)
Inadequate education, particularly of females, has important negative effects on caring and self-care practices, on the utilization of health services, on family hygiene and on food security.

And all of these are affected by economic status, governance and other “basic causes.” Using this conceptual framework, the relationship with nutrition of each of the sectors discussed below becomes clear.
Page 9 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 5: Determinants of Child Nutrition Water, Sanitation and Hygiene (WASH) As reflected in 5 above, poor environment (unsafe drinking water and poor sanitation and hygiene), underlying determinants of malnutrition, often lead to increases in diarrheal disease, a leading cause of child death in Pakistan, which decreases the absorption of nutrients consumed.
Accordingly, even when food consumption is sufficient, such bacterial, infection can lead to malnutrition in children (WHO, 2008.)

Additionally, open defecation, improper sanitation facilities and unsanitary waste disposal contaminate food in the household as well as food production.
Although a large majority of households in KP utilize water for drinking that is safe at its source (93.0%), it is important to note that there are numerous opportunities for pathogens to make their way into the water prior to ingestion, during water collection, transport, storage and/or transfer to drinking vessels.
Page 10 of 28 Child Malnutrition Inadequate dietary intake Disease Inadequate care for children & women Inadequate access to food Insufficient health services & unhealthy environment Resources and Control Human, economic and organizational resources Maternal Malnutrition Potential resources Inadequate education Political and ideological factors Economic structure Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Nearly 20% of households in KP do not have access to hygienic sanitary facilities.
While hand washing after defecation and before preparation of a meal (98.4% and 97.9% respectively) is substantially higher than that in many developing countries, soap is not available in over 30% of households (30.5%) As seen in Figure 6 below, there is a moderate but statistically significant association between the absence of soap and stunting.
Figure 7 and Figure 8, presenting associations between anemia in young children and open defecation, indicate that in KP households practicing open defecation, 33% of young children are severely anemic, 67% are moderately anemic and none are normal, while in households not practicing open defecation only 6% are severely anemic while 52% are normal.
Figure 6: Stunting by Soap Availability for Handwashing Figure 7: Anemia among children practicing open defecation 80 60 40 20 0 67 33 Severe anemia Moderate anemia Normal 0 Page 11 of 28 47560102030405060Soap available in the householdSoap not availableStunting Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 8: Anemia among children not practicing open defecation 52 42 60 50 40 30 20 10 0 6 Severe anemia Moderate anemia Normal Food Security Food insecurity, the limited or uncertain availability of or access to nutritionally adequate and safe foods throughout the year, is associated with malnutrition as a key underlying determinant of overall food intake in the household (see Fig.
5), although often less well associated with the intake of women and children.10 Food insecurity may also be a more sensitive measure of food issues experienced by low-income families than household income alone, especially the psychological and social ramifications of a lack of food (Frangillio, 1999.)
In KP, with a scarcity of cultivated land, food shortages and relatively higher food prices in markets, high population density, small landholdings, and depleting livelihood sources, nearly one third of households (32%) are food insecure.

Of these, 6% are classified as food “insecure with hunger,” and 5% are food insecure with severe hunger.

Only one of KP’s districts is sufficient in food production, while the remaining 23 districts are deficient.
The inadequacy of agriculture in the province also is reflected by the fact that income from agriculture (both crop and livestock) amounts to only 15 percent of average monthly income (UNDP 2011.)

Figure 9 below, indicates that stunting is significantly higher in food insecure households.

But, importantly, even in food secure households, stunting affects 44% of young children, indicating that food security improvement alone in KP is insufficient.
10 The influence of food supply and access on nutritional status of children can be confounded by other key determinants of child nutrition, such as maternal knowledge and caring practices, maternal nutritional status, intra-household food allocation and utilization, access to health services, and WASH factors.

(Chamarbagwala R et al, 2004.)
Page 12 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 9: Food Security and Stunting 44 50 60 50 40 30 20 10 0 Food secure Food insecure with moderate to severe hunger Agricultural and food-related interventions seeking to reduce food insecurity are also likely to reduce malnutrition if they (1) focus on the diversity of food consumption and not simply the quantity; (2) provide special attention to agricultural tasks disproportionately undertaken by women and provide extension services to women directly;11 and (3) encourage home garden and small livestock production for home consumption.
Additionally the micronutrient fortification of food products: wheat, edible oil and salt, and the bio-fortification of food staples12 are important means of reducing malnutrition.

Utilization of Health Services As indicated in Fig 5, households with regular access to health services (another underlying determinant of nutrition) may experience lower rates of morbidity and, in turn, reduced malnutrition.
Proxies for such access may be ante-natal care, immunization rates or the presence of an immunization card.

The secondary analysis of the 2011 NSS data actually found an inverse but statistically significant association between the absence of an immunization card and stunting,13 this likely explained in part by the high percentage of households using private facilities and practitioners, as discussed below.

Coverage of health services relating to nutrition in KP is relatively low.
Of reproductive women surveyed, 44% received no ante-natal care during their last pregnancy.

Of women receiving ANC, only 0.4% received information on the importance of exclusive breastfeeding and none received 11 In KP, women’s agricultural work often includes responsibility for livestock; transplanting; hand harvesting; cleaning, processing and storage of grain, and garden work.
12 HarvestPlus testing of wheat varieties with high zinc content is currently underway in Pakistan and India (HarvestPlus, 2011.)

13 Of households with a child immunization card, 47.6% were growing normally while 52.4% were stunted; p=<.005.

Page 13 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa information on family planning.

Relatedly, over a third of women (33.7%) reported receiving no micronutrient supplements during their last pregnancy.
The consequences of such inadequate health services for pregnant women at a national level, coupled with inadequate food consumption, virtually non-existent services for adolescent girls and early age of marriage are particularly serious in terms of pregnancy outcomes in Pakistan and result in the highest recorded prevalence of low birthweight in Asia (32%.

)14 Of young children in KP, only 52% are fully immunized (Pakistan Social and Living Standards Measurement Survey, 2011.)
Another indicator of the utilization of government health services is the type of practitioner consulted for illnesses.

As seen in Table 2 below on the type of practitioner consulted for childhood diarrhea in KP, 32% of households used government facilities while 66% used private dispensaries or hospitals.

Only 1% of households consulted with LHWs.


These figures suggest the need to make government facilities significantly more attractive and/or to more fully engage private practitioners and facilities in nutrition services.
Table 2: Type of practitioner consulted for childhood diarrhea15 Private dispensary or hospital Government dispensary or hospital Rural health center or Basic health unit Local Health Worker Infant and Young Child Feeding Practices (IYCF) KP 45% 22% 10% 1% Pakistan 66% 17% 6% 1% Although IYCF practices relate to several different sectors, they are placed under the Health sector in this Nutrition Guidance Note given that the health sector often has primary responsibility for addressing these practices.
As indicated in Figure 5, inadequate caring practices are a key underlying determinant of malnutrition.

Fortunately, KP has a culture of continued breastfeeding.

But, as seen in Table 3 below, it faces problems of late initiation of breastfeeding, inadequate exclusive breastfeeding for six months, delayed introduction of complementary food, and extremely low dietary diversity among children.
Table 3: IYCF Practices in KP Indicator Initiation of breastfeeding within 1 hour of birth NNS % 28 14 There is no official birthweight data from Afghanistan.

Internationally only Mauritania has a higher prevalence at 34% (UNICEF, State of the World’s Children, 2012.)
15 Pakistan Social and Living Standards Measurement Survey, 2011 Page 14 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Exclusive breastfeeding up to 6 months Continuous breastfeeding until at least 12- 15 months Introduction of semi-solid food between 6- 8 months Minimum acceptable dietary diversity 6-23 months 45 (MICS 2008) 87 36 3 Priority attention to breastfeeding in KP is justified given that breastfed infants have a lower risk of mortality,16 lower rates of infection, lower rates of stunting, fewer allergies, and a lower risk of cardiovascular disease as adults.
Advantages to breastfeeding women include a lower risk of breast and ovarian cancer, reduced fertility during the period of breastfeeding, better bone density, and a lower risk of hip fractures.

The timely introduction of nutritionally adequate complementary food has been found to be highly effective in improving child growth.

However, international assessments of unfortified complementary foods have found that they rarely contain adequate iron, zinc or vitamin B6 (Dewey KG, 2000.)
This argues both for special attention to dietary diversity in the preparation of such foods, and for the consideration of micronutrient powders to increase their nutrient value.
Education of Girls As reflected in Figure 5, education of girls affects each of the underlying determinants of nutrition by permitting them, as women, to make better use of available information and hence more informed choices about child nutrition and health and about self-care.17 Better educated women also have a greater decision making role in the household to permit the implementation of these choices.
In some cases, better education for women translates into higher household income The female literacy rate in KP, 27.8%, compares with a figure of 40.7% for the country as a whole.

(Literacy among household heads in KP is 55.4%.)

16 The Lancet Nutrition Series found that 99% coverage of exclusive breastfeeding plus continued breastfeeding up to 12 months of age can reduce under-5 mortality by 13%, while the same coverage of complementary feeding can reduce under-5 mortality by 6% (Lancet, 2008.)
17 It appears, however, that effective information dissemination, increasing knowledge about nutrition and health can compensate, fully or partially, for inadequacies in formal education.

Some studies have found that education itself does not have a significant effect on nutrition once health knowledge is controlled for (Glewwe, 1999.)
Page 15 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 10: Gender Equity Trends in School Enrollment in KP 100 94 93 120 100 80 60 40 20 0 76 66 53 71 61 52 67 62 61 41 31 23 35 23 20 2001-2002 2004-2005 2010-2011 Male Female Male Female Male Female 6-10 years Primary 10-12 years Middle 14-15 years Matric Level Data Source: PSLM 01/02, 04/05 and 10/11 As seen in Figure 10 above, female primary school enrollment in KP is 76% which drops to 41% for middle school, both figures well below those for males.
The Gender Parity Index (GPI) for primary education in KP is 0.76 compared to 0.84 for the country as a whole.18 19 Stunting levels are higher in households where mothers are illiterate, compared with those who are better educated, but the relationship is uneven as seen in Figure 11 below.

18 The GPI, in this case, is calculated by dividing the female enrollment rate by the male enrollment rate.
19 Higher opportunity costs of education for girls (who are often responsible for household chores and the care of younger siblings and the elderly) and lower investments in girls’ schools increase gender disparities in education in the province.
Youth employment, lack of access to schools, lack of quality education, absence of sanitary facilities, malpractice by the teachers, lack of availability of female teachers, and early marriage also contribute to low female enrollment, a high dropout rate and, in turn, a large pool of out-of-school children.
Page 16 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 11: Mother’s Education and Child Stunting 60 49 45 41 33 d e t n u t s n e r d l i h c f o % 70 60 50 40 30 20 10 0 Illiterate Primary Middle Matric Above Matric Poverty Alleviation and Social Protection Figure 5 identifies inadequate economic resources as a basic determinant of malnutrition affecting each of the underlying determinants.
While international evidence indicates that the income-child nutrition relationship itself is modest and not rapid, nutrition gains are possible through social protection programs when they are able to protect families against household shocks and when resources, coupled with counseling are made available to women.
livelihood The deteriorating security situation opportunities.20 The Pakistan Social and Living Standards Measurement Survey of 2011 found that 40% of households surveyed in KP believed their economic situation to be “much worse” or “worse” than the year before, while less than 2% believed it to be “better or “much better.” in the province has negatively affected As seen in Figure 12 below, stunting prevalence falls only between the top two wealth quintiles suggesting a relatively poor translation in the province of increased income into better feeding and care practices for young children.
Additionally, stunting in the wealthiest quintile is 34%, clearly indicating that reducing poverty alone won’t eradicate malnutrition, and that important behavioral issues need to be addressed even among the economically advantaged.21 20 Poverty in KP is reflected by the low percentage of household dwellings with cement or slake lime floors (45%.)

21 Stunting prevalence in the highest quintile in KP, 34%, is higher than the national average for Senegal, Zimbabwe and Sri Lanka.
And wasting in the highest quintile in KP, 27%, far exceeds the WHO public health emergency threshold level.
Page 17 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Figure 12: Child Stunting and Wasting by Wealth Quintile 53 46 47 46 24 18 22 22 34 27 Wasting Stunting 60 50 40 30 20 10 0 800 to <6000 6000 to <9000 9000 to <12000 12000 to <20000 >=20000 Social protection efforts to generate employment and income and to protect households against the manifestations of poverty and against household shocks (e.g.
serious illness and hospitalization), can be particularly useful for nutrition if they are targeted to women.

Studies have shown that additional income tends to be spent on food and on family health when women are the recipients of the transfer, and that this increased spending, if the transfer is large enough, can lead to a reduction in levels of malnutrition within the household.
Where transfers are conditional, and where health services and/or schools are of adequate quality and able to absorb increased demand, the health services or education provided can, in the longer run pull families out of poverty (Bassett L, 2008.)

The Pakistan Government’s Benazir Income Support Program (BISP) is an unconditional cash transfer program that delivers Rs.

1,000 (US$11) to female beneficiaries in households with a monthly income below Rs.

6,000.
6,000.

In 2010, about 7% of the country’s population was benefiting from the transfers.

The BISP also includes microcredit financial assistance, and is pilot testing health and life insurance coverage and vocational skills training (Channa A, 2012.)

The BISP infrastructure – a national database, a network of ATM and point-of-sale terminals, and planned community mobilization days to support registration and enrollment, has particular potential to provide multiplier benefits for nutrition.
Among possibilities appropriate for piloting are:  Subsidized distribution of vouchers to BISP’s targeted low income household, enabling beneficiaries to purchase nutrition-related products, e.g.

multi-micronutrient powders, soap, water purifiers;  Utilization of cell phones (owned by 56% of BISP’s beneficiaries) to provide/reinforce key information tailored to pregnancy or early childhood as appropriate.
Page 18 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Conclusions and Recommendations The data presented above indicate that while intensified action in each of the concerned sectors will reduce malnutrition, no sector alone can reduce malnutrition to the point where it ceases to become a public health problem – and that only in combination are they likely to achieve desired nutrition targets.
At the same time, reductions in malnutrition are likely to lead to benefits for each of the sectors:  Healthier and more productive farmers  Better school attendance and improved active learning capacity  Reduced infectious disease and mortality  Reduced vulnerability and poverty The recommendations below relate to (a) interventions, (b) coordination and advocacy, and (c) cross-cutting issues.
Intervention-related Recommendations Clearly a large number of sector-specific recommendations can be made based on the KP information presented above.

This Guidance Note however seeks to narrow these recommendations to the most critical and the most feasible over the next five year period.

Recommendations are organized by sector.
Water, Sanitation and Hygiene Increased access to water supply and sanitation throughout the province • Engagement of school children as social change agents for hand washing in homes • • As prioritized by the province, improved water quality monitoring and mapping, establishment of water filtration plants, rehabilitation of existing water supply increased household water infrastructure, treatment, soap provision, and awareness creation and hygiene counseling in targeted poor and marginalized communities improved solid waste management, Food Security • Intensification of existing KP efforts to incorporate nutrition into agricultural policy including increased resource allocation for diversification and efforts to reduce food insecurity among subsistence farm families through subsidized inputs, interest free loans, reduction of post-harvest losses, improved supply chain management, reclamation of cultivatable waste land (1.08 million hectares in the province), and prioritized research on high nutrient crops Page 19 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa • Based on KP priorities, a simultaneous focus on improved production of foods consumed directly by rural households, i.e.
kitchen gardens, and household level meat, milk and poultry production, facilitated by farm service centers and farmer field schools • Mandatory micronutrient fortification of wheat in the province’s 184 flour mills through legislation (using elemental iron as determined by the province), and edible oil to address provincial micronutrient deficiencies, with provision of micro-feeders and micronutrients as determined by dialogue between provincial governments and development partners.
Such fortification requires active private sector involvement, including the development of regulatory monitoring systems to ensure sustainability.
The high levels of vitamin A deficiency among women indicate the particular value of edible oil fortification in the province Utilization of Health Services (including Infant and Young Child Feeding) • Consistent with identified provincial priorities, provision of in-service training for existing BHU and RHC staff on facility-based and community-based delivery of key nutrition services • • Given low prevalence in the province of immediate initiation of breastfeeding, of exclusive breastfeeding for six months, of timely introduction of complementary feeding, and of dietary diversity for young children, intensified self-care and IYCF counseling of pregnant women and mothers at the community and facility levels and through social protection platforms reinforced by media Increased coverage of micronutrient supplementation with special attention to current deficiencies in the province, i.e.
zinc to children for treatment of diarrhea, iron/folate supplementation for women, vitamin A supplementation, multi-micronutrient powders for young children, and increased coverage of iodized salt Increased LHW coverage, or alternate modes of community outreach (e.g.
NGO contracts) in low-coverage districts Increased coverage and improved management of severe acute malnutrition, particularly at the community level, given high prevalence in the province • • • • Inclusion of nutrition indicators in DHIS Increased coverage and improved management of severe acute malnutrition, particularly at the community level, given high prevalence in the province.
Page 20 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Education • As proposed by the province, increased female school enrollment, retention and attendance by addressing existing constraints and through incentive provision adequate to compensate for high opportunity costs.

The Society for the Protection of the Rights of the Child (SPARC) may be a valuable partner in this undertaking.
• Simultaneous inclusion of nutrition in pre-, primary, middle and high school curricula, increased support for school nutrition programs, teacher sensitization and training, and involvement of students and teachers in an annual National Nutrition Day • Deworming for pre- and primary school children • Use of iodized salt where school meals are provided • Weekly iron folate distribution and counseling (health nutrition and life skills counseling) for adolescent girls including those out of school.
Poverty Alleviation and Social Protection • Expansion and improved targeting of social protection programs and of interventions under the KP Child Protection Act with continued utilization of social protection platform for nutrition message dissemination • Piloting of a (conditional) cash transfer program using vouchers and linked to the utilization of health and nutrition services by target population groups, while being particularly attentive to supply side constraints which may be encountered by these groups Coordination and Advocacy It is anticipated that a mechanism for coordination, the identification of responsible individuals in each department of sector, and a coordinated monitoring and evaluation plan (including the strengthening of DHIS and surveillance systems) for strategy implementation will emerge from the Provincial Integrated Nutrition Strategy (PINS) process which is underway.
Multisectoral experience in nutrition from countries like Nepal, Afghanistan, Thailand, Peru and Brazil shows that a centrally-placed coordination mechanism is imperative for ‘planning multisectorally, implementing sectorally, and reviewing programs multisectorally’.

The centrally- placed coordination mechanism should be equipped to manage horizontal integration across sectors and vertical integration among levels of government.
Such a mechanism requires results- based monitoring tools and perhaps results based budgeting, focusing not solely on provincial “average” figures but also e.g.

on poorest wealth quintiles.

The PINS process, also will seek to strengthen government commitment to nutrition and to multisectoral nutrition processes.

The planned political economy analysis in the province should be helpful in these respects.
Page 21 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Attention to Cross-Cutting Issues Gender As is clear from information presented in the Brief, gender-related issues are important determinants of nutrition, some of the most important being (a) the inadequate food intake (quantity and quality), inadequate health service access and the arduous labor of many women, particularly pregnant women affecting pregnancy outcomes including birthweights and, in turn, the nutritional status of young children, and (b) inadequate education of girls and low female literacy adversely affecting food consumption, health care, hygiene and sanitation and food production choices and decision making.
Given high maternal mortality, the low service provision for women, and the serious levels of food insecurity, the highest priority gender and nutrition-related recommendations are the following which reinforce the intervention recommendations presented above:  An intensified, province-wide focus on healthy pregnancies and, in turn deliveries, increasing ANC coverage and iron-folate distribution, improved food intake and reproductive health counseling;  Improved school enrollment and attendance for girls; nutrition and life skills counseling and weekly iron tablets for all adolescent girls; and  Prioritized agricultural extension services for women designed to increase the efficiency of their work and reduce arduous labor.
Private Sector While the primary focus of this guidance note is on the role of the provincial government and its development partners, it should be clear that there also is an important role for the private sector in these multisectoral efforts to reduce malnutrition in the province.
The private sector has a particularly important role to play in the food chain, in producing micronutrient and therapeutic food supplements, in increasing soap accessibility and promoting hygiene behaviors, in food fortification in behavioral change efforts through media.
Recommended is the following:  A process of consultation and discussion between provincial government and private sector representatives to explore mutually beneficial means of addressing the recommendations contained in this guidance note, particularly in those areas identified in the preceding paragraph  Active consideration of engagement of private sector medical practitioners and facilities in efforts to prevent and treat malnutrition.
Page 22 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa References Barker, D.J.P.

(1997).

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807 Bassett L, 2008.

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SP Discussion Paper 0835, World Bank Behrman J and Rosenzweig R, 2001.
“The Returns to Increasing Body Weight.” Penn Institute for Economic Research, Working Paper 01-052 Chamarbagwala R, Ranger M, Waddington H, White H, 2004.

The determinants of child health and nutrition: A meta-analysis.

World Bank Channa A, 2012.

Background Paper Social Protection in Pakistan: A Profile of Existing Programs and an Assessment of Data Available for Analysis, Asia Research Centre, London School of Economics.

Dewey KG, 2000.
Dewey KG, 2000.

Approaches for improving complementary feeding of infants and young children.

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Frongillio E, 1999.

Validation of measures of food insecurity and hunger.

J Nutr;129(suppl):506S–9S.

Glewwe P, Koch S, Nguyen B, 2002.

"Child nutrition, economic growth and the provision of health care services in Vietnam in the 1990s," Washington, DC: The World Bank.

Grantham-McGregor S, Fernald L, Sethurahman K, 1999.
“Effects of Health and Nutrition on Cognitive and Behavioral Development in Children in the First Three Years of Life.” Food and Nutrition Bulletin 20(1).

Gross R, Webb P (2006).

Wasting time for wasted children: severe child undernutrition must be resolved in non-emergency settings.

Lancet 2006; 367: 1209–11 Hallman, K. “Women, Still the key to food and nutrition security.” IFPRI Hoddinott et al, 2008.Copenhagen Consensus presentation.

Horton, Susan, and J. Ross.

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“The Economics of Iron Deficiency.” Food Policy 28(1) Horton S, Shekar M, McDonald C, Mahal A, Brooks J, 2010.

“Scaling-Up Nutrition; What Will it Cost?” Directions in Development.

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“The Potential Impact of Reducing Global Malnutrition on Poverty Reduction and Economic Development.” Asia Pac J Clin Nutr 14(S).

Page 23 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Jafar T, Chaturvedi N, Pappas G, 2006.
Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population.

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175 no.9 KP MICS 2009-10 KP PDHS 2006/07 Lancet Nutrition Series, 2008.

Pakistan Social and Living Standards Measurement (PSLM) Survey 2001- 2011 Save the Children, 2012.

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WHO, 2008.
WHO, 2008.

“Safer Water, Better Health: Costs, Benefits and Sustainability to Interventions to Protect and Promote Health.” Page 24 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Appendix-1: Overweight and Obesity in Pakistan The NSS 2011 found that 28.8% of Pakistani aged 15-49 are overweight or obese, a figure surprisingly high for a country of Pakistan’s economic status, and one with serious implications in terms of medical consequences.
Analysis done on an earlier Pakistan data set (the National Health Survey, 1990-94) found a prevalence figure of 25% for Pakistani women and men over the age of 15 and through multivariate analysis found the factors independently and significantly associated with overweight and obesity to be greater age (highest among women aged 35-54 years), being female, urban residence (obesity was 2.5 times greater among urban residents), being literate, having a high economic status and a high intake of meat (Jafar T et al, 2006.)
A preliminary analysis carried out on the NSS 2011 data, explored the possibility that a significant portion of the overweight and obesity found might be explained by the Barker hypothesis suggesting that one of multiple biologic consequences of fetal and early malnutrition can be an inability by the body to oxidize fat properly (Barker D, 1997.)

This was examined by looking at the association between overweight and obesity in pregnancy and stunting in young children in the same family.
Although the aggregate analysis found no statistically significant association, it remains likely that a significant percentage of lower income overweight and obese women suffered themselves from fetal or young child malnutrition.

The analysis, however, found that overweight and obesity are disproportionately concentrated in higher income groups and among better educated women (these two variables themselves being closely associated.)
Of women who are overweight or obese, 30.6% are in households with a monthly household income of Rs.

20,000 or more, while among underweight women, only 14.7% are in this high income bracket.

Similarly, of women who are overweight or obese, 28.2 are “matric” or “above matric” while among underweight women, only 11.8% have that level of education (Chi square: p=<.001.)
Preliminary analysis also found that 59.1% of underweight women suffer from moderate or severe compared with 44.6% for women who are overweight and obese.

See Table 4 below.

Table 4: BMI Status by Education, Income and Anemia Indicators Underweight 11.8% 14.7% 59.1% Matric + Above Matric* Average Monthly Income Rs.
20,000+* Moderate + Severe Anemia* *Chi square p=<.001 Overweight + Obese 28.2% 30.6% 44.6% Priorities for future inquiry would be attitudinal research on Pakistani women (and men) seeking to understand motivations relating to ideal body size, the associations made between these ideals and food consumption, and present understandings that exist about the consequences of overweight and obesity among this population; and also further disaggregated statistical analysis on overweight and obese women from lower income groups.
Page 25 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Appendix-2: Update on Process for Development of Nutrition Policy and Multisectoral Integrated Strategy in Khyber Pakhtunkhwa 1.

Health, nutrition and population policies play a pivotal role in economic and human development and in poverty alleviation.

Nutrition remains a key element in ensuring food security.

Recent evidences suggest that Pakistan has some of the worst development indicators in the world.
Results from the latest National Nutrition Survey (NNS, 2011) show an alarming nutrition situation in Khyber Pakhtunkhwa.

Under-nutrition is one of the main causes of death among infants and young children.

Those who survive have less learning capacity that reduces their productivity at adulthood, which impact negatively on economy.

Reversing adverse trends in nutrition needs appropriate policy direction, political commitment and a concerted effort from all sectors.
Pakistan in general and the province of Khyber Pakhtunkhwa in particular faces many challenges in the formulation and implementation of nutrition policies/strategies and action plans that are holistic in approach to addressing nutrition issues.

2.

Addressing malnutrition comprehensively remains a national challenge and immediate provincial responsibility.

A substantial economic loss has been occurring on account of waste of human potential due to malnutrition and its implications.
Whereas contrary, investment of only a small fraction of that amount would suffice to address malnutrition holistically.

However, fragmented and piece meal intervention in the recent past have not been able to address the persistent level of malnutrition in the country and province.

Traditionally nutrition has been viewed as a problem to be looked after only by the health sector.
Conventional understanding about nutrition to be looked after by the health sector alone skewed the root cause focus of lack of food, clean water, sanitation, education etc.

particularly effecting mothers and children.

3.

Department of Health, Government of Khyber Pakhtunkhwa in collaboration with UNICEF organized Provincial Launching ceremony of National Nutrition Survey Report (NNS 2011) and adoption of Pakistan Integrated Nutrition Strategy for KP in November 2011.
The event was attended by large number of participants, including very senior officers from health, district EDOs Health, senior officials of line departments of Government of KP, UN partners (UNICEF, WHO, UNFPA, WFP), representatives from Civil Society Organization and media.

4.
4.

In the process of revisiting the prevalent nutrition scenario, the Planning & Development Department, convened a meeting in June 2012, which reviewed the progress against targets in health and nutrition agenda including updates on the Provincial Integrated Nutrition Strategy.

The strategy agreed in the meeting recognizes the need for a long-term and multi-sectoral approach encompassing the immediate, underlying, and basic causes of malnutrition.
The INS will be going beyond the Health Sector and capitalizing on other sectors such as Education, Food & Agriculture, Water & Sanitation, Planning and Development, Finance, Social Page 26 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa Protection, Social Welfare, and other, however to be coordinated and steered by an appropriate provincial level authority for a successful follow-up.

5.
5.

The devolution on the other hand maintained nutrition as a national issue, with joint provincial responsibility to address root causes of malnutrition.

The D-10 meeting held in EAD in September 2011followed by a national review meeting at the planning commission in February 2012 revealed that the engagement on the nutrition issues was still weak in departments other than health.
A concurrent technical support was made available through a group of development partners designated by the D-10 forum as “Pakistan Nutrition Development Partners” coordinated by the World Bank for province specific plan.

The group worked with each province to develop policy guidance note and framework on multi-sectoral concept of food and nutrition security following a consultative process through engagement of all stakeholders and partners from relevant sectors.
The policy guidance notes for the province has now been developed to outline the scope of the malnutrition problem and present policy recommendations along with strategic and operational plan that will identify practical actions to be taken across sectors to address the problem in the province.

6.
6.

The Planning & Development Department having the nodal policy, planning and development role in the province agreed to be a lead department for overall policy formulation and inter- sectoral coordination in the province.

To take forward the process a two days consultative workshop convened by Planning and Development under the directives of Additional Chief Secretary was held in Peshawar on August 29-30, 2012.
The consultative workshop was chaired by the ACS (Development), while Secretary P&DD chaired technical sessions of the workshop.

Key message agreed during the workshop was “addressing malnutrition is a collective responsibility of many sectors beyond the health sector and that we need to develop a comprehensive policy, strategy and plan to address the issue of malnutrition”.
Planning & Development department supported the idea and agreed to take the lead role to coordinate among all concerned sectors, partners, academia and communities in order to develop the policy and strategy, to follow up for its implementation, exert efforts for resource allocation and undertake alignments where and when required.
For effective implementation of the multi-sectoral nutrition program in Khyber Pakhtunkhwa, a high level steering committee was constituted on November 20, 2012 under the directives of Additional Chief Secretary (Development).

ACS (Development) as chairman and secretaries of the selected departments as its members.

Similarly a Technical Working Group at the P&DD level was constituted to assist the steering committee in Technical matters related to implementation of the multisectoral nutrition strategies.
Technical Working within each department including health, education, agriculture, food, LGRDD, PHED and Social Welfare department were also notified.

7.
7.

The Nutrition Policy Guidance Notes for Khyber Pakhtunkhwa developed with support of world bank in close consultation with the relevant departments were reviewed extensively, comments and inputs from the sectors were incorporated as and when provided and were finally cleared by the Technical Working Group on April 19, 2013 and recommended for Page 27 of 28 Nutrition Policy Guidance Note-Khyber Pakhtunkhwa approval of the steering committee.
Multi-sectoral Provincial Integrated Nutrition Strategy has been drafted and is in the finalization phase.

To be approved by the Steering Committee.


Meeting of the steering committee was convened on August 19, 2013 to update the members on the progress and process of the nutrition policy guidance notes and strategy and get it endorsed by the steering committee for wide circulation, Beside advice of the steering committee was sought for continuation of processing multisectoral Integrated Nutrition Strategy for next meeting of the steering committee.
Advice was also sought on establishment of Nutrition Section in P&D Department to tackle the longstanding and ongoing issue of malnutrition through a multi-sectoral approach, but was postponed due to non-participation of senior level management from the concerned administrative departments.

8.
8.

The Additional Chief Secretary, Khyber Pakhtunkhwa approved the nutrition policy guidance note, after getting a positive signal from the members / representative of the Steering Committee attending the Scaling Up Nutrition (SUN) meeting on September 5, 2013 at P&DD based on the endorsement of the guidance notes by the members of Technical Working Group of the departments previously on April 19, 2013.

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