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1 NATIONAL NUTRITION SURVEY 2018 - KFR 2 LINE RES U L T P O T S O F K P STUNTING 40.0% 60.8% 70.9% 46.9% EXCLUSIVE BREASTFEEDING FOOD SECURITY EARLY INITIATION OF BREASTFEEDING Preamble: The 2018 Pakistan National Nutrition Survey (NNS 2018), the largest national nutrition survey, in Pakistan.

It is designed to provide to policymakers, programme managers and academicians a unique set of nutrition- related data including environmental, anthropometric and biochemical indicators.
The study group included children, women of reproductive age (WRA) and adolescent boys and girls.

NNS 2018 is the fifth national nutrition survey since 1965, but the first to yield district-representative data and to include adolescents and a component on water.

NNS 2018 employed a cross-sectional survey design at the household level.

It used a mixed-method data collection methodology with both quantitative and qualitative approaches.
The sample design provides district level estimation at the national level for urban and rural localities and by gender, for the four provinces (Punjab, Sindh, Balochistan and Khyber Pakhtunkhwa, KP); and for the regions (Azad Jammu and Kashmir, AJK, and Gilgit-Baltistan, GB), KP-NMD and Islamabad Capital Territory (ICT).
Ministry of National Health Services Regulation & Coordination, UNICEF and Aga Khan University, with funding support from Department for International Development (DFID) conducted National Nutrition Survey 2017-18.

The survey was managed and supervised by MoNHSR & C at national level under the guidance of Technical and Steering committees.

The provincial Department of Health (DoH) supported and monitored the implementation of data collection process in the respective provinces.
The survey was conducted by Aga Khan University on a district specific sample in all provinces and regions of Pakistan.

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6 8 4 3 4 0 0 5 0 0 5 5 r e d n u n e r d l i h C ) s r a e y 9 1 - 0 1 ( t n e c s e o d A l ) s r a e y 9 4 - 5 1 ( NATIONAL NUTRITION SURVEY 2018 - KFR 4 NUTRITIONAL STATUS OF CHILDREN UNDER FIVE YEARS OF AGE Prevalence of Malnutrition by gender (Children under Five) 40.0% STUNTED 15.0% WASTED 23.1% UNDERWEIGHT 12.9% OVERWEIGHT The burden of malnutrition in KP is becoming increasingly apparent, with 23.1% of children being underweight, contrasting a low prevalence of overweight (12.9%) in the same age group.
The highest proportion of malnutrition is in stunted children, at 40.0%.

Stunted Wasted 34.7% 13.2% Underweight 18.6% Overweight 12.4% URBAN Stunted Wasted 41.4% 15.5% Underweight 24.3% Overweight 13.1% RURAL Children living in rural areas suffer more from undernutrition (wasting, stunting and underweight) than their counterparts in urban areas.

Overweight affects rural children slightly more than urban (13.1% compared to 12.4%).
NATIONAL NUTRITION SURVEY 2018 - KFR 5 Prevalence of Malnutrition by gender 42.2% 37.9% 23.6% 22.7% 14.3% 15.7% 12.9% 12.9% STUNTED WASTED UNDERWEIGHT OVERWEIGHT Boys Girls The pattern of distribution of malnutrition among boys and girls remains the same, with boys being more affected than girls by almost all forms of malnutrition except for wasting, where girls are 15.7% compared to boys at 14.3%.

The only category where the proportions are equal is in the overweight category, reporting 12.9% in both.
Prevalence of stunting National Nutration Survey 2018 Stunting In KPK, the highest concentration of stunting is seen in Tor Ghar, followed by Dera Ismail Khan, Tank, and Buner.

The lowest concentration is in Peshawar, Nowshera, Swabi, and Malakand.

Lower concentrations are mostly in the upper Northern districts and in the central zones.
NATIONAL NUTRITION SURVEY 2018 - KFR 6 Prevalence of Wasting Wasting is prevalent in only a handful of districts in KPK: Shangla, Malakand, Battagram, and Swabi, followed by Charsadda and Bannu.

The lowest concentration of wasting is in the Northernmost districts such as Chitral, Kohistan, and Swat, as well as some Southern districts such as Tank and Lakki Marwat.
NATIONAL NUTRITION SURVEY 2018 - KFR Prevalence of Under-weight 7 Most districts across KPK have a low concentration of underweight children under 5, with the lowest being in Swat and Mardan.

The districts with moderate concentrations of underweight children were Dera Ismail Khan, Upper Dir, and Malakand.

The highest concentrations, which were very few in number, were Shangla, Battagram, and Tor Ghar.
Prevalence of Over-weight NATIONAL NUTRITION SURVEY 2018 - KFR 8 Trends in malnutrition 100 90 80 70 60 50 40 30 20 10 0 N N S-2 0 0 1 N N S-2 0 1 1 N N S-2 0 1 8 Stunted Wasted Underweight The trend of wasting in children under 5 has stayed stagnant from NNS-2001 to NNS-2011, and slightly increased from the 2011 to the 2018 report.

Comparatively, stunted and overweight have had opposite trends from each other.

Underweight has decreased from NNS-2001 to NNS-2011, by approximately 10%.
Meanwhile, stunting has increased from NNS-2001 to NNS-2011 by less than 10%, and then continued to decrease slightly until NNS-2018.

Anemia in Children Under Five 100 90 80 70 60 50 40 30 20 10 0 54.2 49.7 55.4 56.5 51.8 6.6 5.0 7.0 5.2 8.0 KP Urban Rural Boys Girls Severe (<7 gm/dL) Moderate (7 - 10.99 gm/dL) In KPK, the overall proportion of moderate anaemia (54.2%) was significantly higher than the proportion of severe anaemia (6.6%).
The prevalence of anaemia is only slightly higher (56.5%) amongst boys than girls (51.8%).

Children in rural areas are more likely to be moderately anaemic (55.4%) than in urban areas (49.7%).

A similar pattern was observed for severe anaemia (rural: 7.0%; urban: 5.0%).

NATIONAL NUTRITION SURVEY 2018 - KFR Ferritin Deficiency among Children under Five 9 100 80 60 40 20 0 33.2 33.9 33.0 32.0 34.5 KP Urban Rural Boys Girls The overall proportion of Ferritin deficiency in children under 5 was 33.2%.
The prevalence of Ferritin deficiency is higher amongst girls (34.5%) than boys (32.0%).

By a small amount, children in urban areas are more likely to have deficiency (33.9%) compared to children in rural areas (33.0%).

Iron Deficiency Anemia Among Children Under Five 100 80 60 40 20 0 20.3 19.1 20.6 19.9 20.7 KP Urban Rural Boys Girls The overall proportion of Iron Deficiency Anaemia in children under 5 was 20.3%.
The prevalence of Iron Deficiency Anaemia is higher amongst girls (20.7%) than boys (19.9%).

Children in rural areas are much more likely to have deficiency (20.6%) compared to children in urban areas (19.1%).

Vitamin A Deficiency among Children under Five 100 90 80 70 60 50 40 30 20 10 0 34.9 35.9 34.6 35.9 33.8 11.8 9.0 12.5 11.8 11.7 KP Urban Rural Boys Girls Severe (<0.35 µmol/L) Moderate (0.35 - 0.70 µmol/L) About 34.9% of children have vitamin A deficiency, of whom 11.8% have a severe deficiency.
Prevalence is slightly higher (35.9%) among boys than in girls (33.8%).

Rural populations have higher proportions for both severe and moderate deficiency as compared to urban populations.
NATIONAL NUTRITION SURVEY 2018 - KFR 10 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Age Appropriate breastfeeding Continued breastfeeding at 2 year Continued breastfeeding at 1 year Exclusive breastfeeding Early initiation of breastfeeding Age Appropriate breastfeeding Continued breastfeeding at 2 year Continued breastfeeding at 1 year Exclusive breastfeeding Early initiation of breastfeeding Age Appropriate breastfeeding Continued breastfeeding at 2 year Continued breastfeeding at 1 year Exclusive breastfeeding Early initiation of breastfeeding 47.3 46.9 64.9 74.5 60.8 0 20 40 60 80 100 46.3 51.5 46.6 48.2 64.4 67.6 76.1 68.8 60.1 63.2 0 20 40 60 80 100 Rural Urban 45.7 48.8 47.5 46.4 60.6 68.8 69.1 61.6 60.1 78.6 0 20 40 60 80 100 Girls Boys Overall prevalence of exclusive breastfeeding is 60.8%, with a high prevalence (74.5%) of mothers continuing breastfeeding at 1 year.
Thereafter, it decreases to 64.9% at two years of age.

Urban and rural distributions show that a larger proportion of rural populations continue breastfeeding at 1 year (76.1%) compared to urban populations (68.8%).

However, a larger proportion of the urban population initiates breastfeeding early (48.2%), compared to rural at 46.6%.

Gender distributions display higher amounts for boys compared to girls in continued breastfeeding at 1 year, at 2 years, and for age appropriate breastfeeding.
NATIONAL NUTRITION SURVEY 2018 - KFR 11 Complementary feeding practices Minimum acceptable diet 3.1 Minimum dietary diversity Minimum meal frequency 12.4 14.1 Initiation of complementary feeding 29.2 0 20 40 60 80 100 Minimum acceptable diet 3.0 3.7 Minimum dietary diversity Minimum meal frequency Initiation of complementary feeding 12.3 12.7 12.7 19.3 28.5 31.9 0 20 40 60 80 100 Rural Urban Minimum acceptable diet 3.3 3.0 Minimum dietary diversity Minimum meal frequency Initiation of complementary feeding 13.9 11.0 15.2 13.0 30.1 28.3 0 20 40 60 80 100 Girls Boys The overall initiation of complementary feeding was 29.2%, compared to the low amount of 3.1% for a minimum acceptable diet.
Dietary diversity was reported at 12.4% overall, 12.7% in the urban population, and 12.3% in the rural population.

The urban (3.7%) and rural (3.0%) population had close proportions of minimum acceptable diet, as did the boys (3.0%) and girls (3.3%) for the same category.

The gender distribution shows that the initiation of complementary feeding was higher in girls (30.1%) than in boys (28.3%).
NATIONAL NUTRITION SURVEY 2018 - KFR 12 ADOLESCENT GIRLS & BOYS (10-19 YEARS) Adolescent girls nutrition (10-19 years) 6.2% 15.3% 8.5% URBAN RURAL 5.1% 14.8% 11.2% 6.6% 15.5% 7.6% Under-weight Over-weight Obese Amongst adolescent girls, underweight is the highest across all categories, followed by overweight, and then obese.

The rural prevalence of overweight is 15.5% compared to the 14.8% in the urban populations.
Obesity in the urban population (11.2%) was significantly higher than the proportion of obesity in the rural population (7.6%).

Adolescent boys nutrition (10-19 years) 13.0% 14.7% 11.9% URBAN RURAL 14.8% 18.6% 7.8% 12.5% 13.7% 13.1% Under-weight Over-weight Obese Amongst adolescent boys, the overall prevalence of overweight is 14.7%, followed by 13.0% of underweight, and lastly 11.9% obese.

The urban prevalence of overweight is 18.6% compared to the 13.7% in the rural populations.
Obesity in the rural population was significantly higher (13.1%) than the rural population (7.8%).

NATIONAL NUTRITION SURVEY 2018 - KFR Under-weight prevalence (10-19 years) girls 13 There is a low prevalence of underweight girls throughout KPK, the lowest being in Swat and Tank, followed by districts such as Chitral, Malakand, Hangu, and Charsadda.

The highest concentration was seen in Shangla.


Under-weight prevalence (10-19 years) boys In adolescent boys, the prevalence of underweight varied across every single district.

The highest prevalence was seen in Shangla, followed by Kohat and Malakand.

The lowest prevalence is scattered across the region: Tank, Charsadda, and Swat.
NATIONAL NUTRITION SURVEY 2018 - KFR 14 Anemia among Adolescent Girls KP URBAN RURAL 0.3% 46.5% 0.0% 43.6% 0.4% 47.4% Severe (<7gm/dL) Moderate (7-11.99gm/dL) Almost half (46.5%) of adolescent girls in Sindh are anaemic, however only 0.3% have severe anaemia.

Adolescent girls in rural areas are more likely (47.4%) to be anaemic than their counterparts in urban areas (43.6%).
NATIONAL NUTRITION SURVEY 2018 - KFR 15 WOMEN OF REPRODUCTIVE AGE (WRA) (15-49YEARS) Nutritional Status of WRA (15-49 years) by Body Mass Index (BMI) 8.3% 28.2% 15.0% URBAN RURAL 7.2% 27.5% 19.6% 8.5% 28.4% 13.8% Under-weight Over-weight Obese Among WRA, the overall prevalence of overweight was 28.2%, followed by 15.0% for obese, and 8.3% for underweight.

Rural WRA had a higher proportion of overweight (28.4%) compared to their urban counterparts (27.5%).
Comparatively, the proportion of rural underweight (8.5%), was higher than the urban underweight amount of 7.2%.

Under-weight prevalence (10-19 years) boys The underweight prevalence was low to moderate across all districts in KPK.

The lowest concentration of underweight was seen in Tank, Swabi, Charsadda, and Malakand.

The highest was seen in Nowshera, Shangla, and Kohistan.
NATIONAL NUTRITION SURVEY 2018 - KFR 16 Over-weight prevalence (WRA) There was a high concentration of overweight WRA in every single district that was surveyed in KPK.

Anemia in WRA KP URBAN RURAL 0.3% 32.6% 0.1% 31.6% 0.4% 32.8% Severe (<7gm/dL) Moderate (7-11.99gm/dL) About 32.6% of WRA are anaemic, with a higher proportion in rural (32.8%) than urban settings (31.6%).
NATIONAL NUTRITION SURVEY 2018 - KFR 17 Ferritin Deficiency among WRA KP 24.3% URBAN RURAL Fe Iron 21.9% 24.9% About 24.3% of WRA have ferritin deficiency, with a slightly higher proportion in rural (24.9%) than urban About 24.3% of WRA have ferritin deficiency, with a slightly higher proportion in rural (24.9%) than urban settings (21.9%).

settings (21.9%).
settings (21.9%).

Iron Deficiency Anemia among WRA KP 8.5% URBAN RURAL Fe Iron 8.7% 8.5% About 8.5% of WRA have iron deficiency anemia, with a slightly higher proportion in urban (8.7%) than rural settings (8.5%).

NATIONAL NUTRITION SURVEY 2018 - KFR 18 Use of Iodized Salt at HH Level 63.7% KP 73.2% URBAN 61.3% RURAL The overall use of iodized salt at the household level was 63.7%, with a significantly higher proportion in urban (73.2%) compared to rural (61.3%).
Urinary Iodine Excretion among WRA KP URBAN RURAL 5.6% 3.4% 6.1% 14.9% 17.1% 14.3% 29.1% 23.2% 30.6% Severe Moderate Mild Overall prevalence of mild urinary iodine excretion is 29.1%, followed by 14.9% moderate, and 5.6% severe.

The urban population of moderate urinary iodine excretion (17.1%) is higher than in the rural population (14.3%).
NATIONAL NUTRITION SURVEY 2018 - KFR 19 Urinary Iodine Excretion (UIE) Among Children Aged 6-12 Years 100 80 60 40 20 0 25.9 27.9 25.5 28.1 24.3 4.9 7.6 7.7 3.5 5.3 7.6 5.5 7.6 4.5 7.7 KP Urban Rural Boys Girls Severe (<20 µg/L) Moderate (20 - 49 µg/L) Mild (50 - 99 µg/L) The survey showed that 25.9% of children aged 6–12 years have mild urinary iodine excretion, with a slightly higher rate amongst boys (28.1%) than girls (24.3%).
Prevalence of severe urinary iodine excretion is slightly higher among rural children (5.3%) than urban children (3.5%).

FOOD INSECURITY 100 80 60 40 20 0 11.8 5.9 KP 11.4 11.8 6.5 12.8 11.8 5.8 11.0 Urban Rural Severe food insecure Moderate food insecure Milld food insecure Overall, 11.8% have severe food insecurity, followed by 11.4% having mild food insecurity, and lastly, 5.9% having moderate food insecurity.
The rural population had the same proportion of severe food insecurity compared to the urban population (11.8%).

However, the urban group had a higher proportion of mild food insecurity (12.8%) than their rural counterpart (11.0%).

Food insecurity Food insecurity was low in several parts of KPK, namely in Dera Ismail Khan, Tank, Lakki Marwat, Swat, and Kohistan.

The lowest concentration was seen in Upper Dir, followed by Shangla, Peshawar, and Tor Ghar.
NATIONAL NUTRITION SURVEY 2018 - KFR 20 I S O D U T S N G I S E D N A M U H y b d e n g i s e D NATIONAL NUTRITION SURVEY 2018 - KFR