survey reports. We do not analyze any micro data, however. An important shortcoming of the review is that the literature for Pakistan is not extensive. For some of the questions in the review, only a small number of studies are available. In those cases, we summarize the findings of the individual studies, and do not attempt to generalize.

We review what is known about nutrition outcomes that studies on Pakistan usually examine: the stunting, underweight, and wasting status of children below five years of age.<sup>5</sup> Pakistan also registers critically poor outcomes in terms of the nutrition status of adolescent girls and women and the micronutrient status of young children.<sup>6</sup> The 2011 National Nutrition Survey (NNS) finds that 54% of children below five years of age are deficient in vitamin A, 39% are deficient in zinc, 40% are deficient in vitamin D, 44% are deficient in iron, and 62% are anemic (Government of Pakistan [GOP] 2013). The survey also finds that 14% of mothers are thin and 34% are overweight; and that 51% of pregnant women are anemic, 46% are deficient in vitamin A, 69% are deficient in vitamin D, 48% are deficient in zinc, and 59% are deficient in calcium. We review the evidence for the country on maternal health and nutrition and child micronutrient status to the extent that studies examine them in relation to stunting, underweight, and wasting status.<sup>7</sup> The remainder of the review is structured as follows. Section 2 briefly discusses the literature search process and the sources of child undernutrition statistics. Section 3 discusses household food consumption. With respect to child undernutrition, Section 4 discusses national levels and subnational variation, Section 5 trends, Section 6 the levels and effects of determinants, and Section 7 the effects of interventions. Section 8 concludes with a discussion on the implications of our findings for further data collection and research, and for policy and practice in Pakistan.

# **2. Literature search and statistics**

To identify studies for the review, we first used Google Scholar as our search engine. The search was restricted to studies published between January 1990 (the year that the first Demographic and Health Survey [DHS] was administered in Pakistan) and October 2016 (when the first draft of the review was completed), in academic journals, reports or books, and working paper series. We searched for relevant key words, in two rounds. In the first round, we searched for general food and nutrition terms and close variants (for example, nutrition, stunting, wasting, underweight, food security, food consumption, calories), combined with location terms (Pakistan, its provinces or territories, and its major cities). In the second round, we searched for potential determinants of undernutrition (for example, breastfeeding, child feeding, diarrhea, child infection, child care,

> 5 Stunting status, measured by low height–for–age, reflects chronic undernutrition, due to inadequate food intake over the long term, or repeated or chronic illness. Thus, this indicator is considered to be insensitive to recent or short-term changes in food intake or health status. Wasting status, measured by low weight–for–height, is considered to reflect acute undernutrition due to a recent drop in food intake or recent acute illness. Underweight status, measured by low weight–for–age, is a hybrid measure of height–for–age and weight–for–height, and thus reflects both acute and chronic undernutrition ( <mark>de Onis and Blossner 2003</mark> ).

> 6 Child micronutrient deficiency can impair growth and development, weaken immunity, and increase the severity of illness. It can also cause disease, such as anemia, night blindness, or goiter (Caulfield et al. 2006; Black 2003; Rivera et al. 2003). The poor nutrition status of the mother can harm the survival, health, growth and development of the child from pregnancy onward (Black et al. 2013; Martin-Gronert and Ozanne 2006; Wu et al. 2004).

> 7 Independent of the link to child anthropometry, few studies exist for the country on the nutrition status of adolescent girls and women, and the micronutrient status of young children (for example, see Habib et al. 2016; Yousafzai et al. 2016; Soofi et al. 2013; Sharieff et al. 2006; Bhutta, Nizami, and Isani 1999).

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