nutrition information sri lanka

7/29/2019 NUTRITION INFORMATION Sri Lanka

1/52

NUTRITION INFORMATION

SYSTEM IN SRI LANKA

Dr. Renuka Jayatissa

(M.B.B.S., M.Sc, MD)

Department of Nutrition

Medical Research Institute

Department of Health services

Sri Lanka

in collaboration with

WORLD BANK

2002


2/52

NIS/MRI

2

CONTENTS

Acknowledgements 3

Chapter 1: Introduction... 4

Chapter 2: Development of NIS.... 6

Chapter 3: Findings of the baseline information .. 15

Chapter 4: Establishment of NIS and use of information . 44

Chapter 5: References 49

Annex 1:

Annex 2:

51

52


3/52

NIS/MRI

3

ACKNOWLEDGEMENTS

I wish to thank WORLD BANK for providing the funds to conduct the study. Special mention must be

made of Dr. Amarasinghe, Co-ordinator, World Bank project for the speedy course of action taken to

release funds.

The members of the Technical Advisory Committee provided an invaluable service in planning the study.

I thank them.

I sincerely thank Dr. C.D. Gunaratne, Director Nutrition, Dept. of Health, Colombo, for all the support,

Prof. Lalani Rajapaksa, Department of Community Medicine, Faculty of Medicine, Colombo and Mrs.

Soma de Silva, UNICEF for providing their expertise in selecting the sample for the study and Prof.

Dulitha Fernando, Professor of Community Medicine, Faculty of Medicine, Colombo, assisted in the

preparation of the Report.

I am grateful to Dr.Gaya Colambage, Director, Medical Research Institute. She gave her best to make

the study a success.

Last, but foremost in mind are the pivotal operators: the Provincial Directors, Principals of the schools,

teachers, parents, and children. To one and all I wish to say am deeply indebted to you for having been

partners in the study.


4/52

NIS/MRI

4

CHAPTER 1

INTRODUCTION

Sri Lanka is an island with a population of approximately 18.7 million. For purposes of administration, Sri

Lanka is divided into 8 Provinces, 25 Districts and 315 Divisional Secretary areas. The Eight Provincial

Directors of Health Services (PDHS) are totally responsible for management and effective

implementation of health services in the respective provinces. Deputy Provincial Directors of Health

Services (DPDHS) assist the eight PDHSs. DPDHS areas are similar to administrative districts, except

for Kilinochchi and Ampara district. Each DPDHS area is sub-divided into several Medical Officers of

Health areas (MOH/DDHS), which are congruent with administrative units, i.e. Divisional Secretariats.

The MOH/DDHS is responsible for the preventive and promotional health care in a defined area, with a

population ranging from 60,000 to 80,000 and has trained staff working at field level (Annual Health

Bulletin, 2000).

Though Sri Lanka has achieved considerable success in the reduction of mortality with increase in the life

expectancy, the load of morbidity that is present in the community has not been commensurate with the

decline in mortality. An important and persisting problem has been the significant level of malnutrition,

affecting particularly infants, children of the younger age groups and pregnant women. Though poverty

does influence levels of under nutrition, poverty alone does not explain the high prevalence of

underweight that persists in Sri Lanka. Educational and cultural factors are likely to play a significant role,

which in turn affect infant and child feeding practices and family attitudes towards nutrition in general

(Ministry of Health Highways and Social services, 1995).

Nutrition information system (NIS) is a system designed to monitor, on a continuous and regular basis,

the food and nutrition situation of a country. It will watch over nutrition in order to make decisions, which

will in turn lead to improvements in nutrition in the population. Sri Lanka is relatively rich in nutritionrelevant data that can be used to build nutrition information system. There is a lot of information collected

routinely in the health sector by different categories of staff and different agencies at different times.

However, it is important to find out what information is really needed to assess the nutritional problems in

the community and what information is related to causality. The micro level assessment of nutritional

factors are very important to counteract the action oriented cycle because the decisions can be taken at

community level by the information collectors themselves rather than waiting till the national interventions

arrived.


5/52

NIS/MRI

5

The following elements exist at present as nutrition information;

Food balance sheet - Statistics Department Data on growth monitoring, - Health Data on health indicators (birth weight, disease pattern) - Health Maternal and child health data - Health

In addition to the above survey data are also available, e.g.,

Socio-economic survey data - Central Bank Demographic and health survey data - Department of Census and Statistics National Health survey - Ministry of Policy Planning Anaemia, Iodine, Vit A surveys - Medical Research Institute

This is an analysis to show how we can use the routinely collected information and survey data as an

action oriented basis. It will be useful to Health workers, Medical officers of Health, Deputy Provincial

Directors, Provincial Directors and Nationally, to assess the situation and the monitoring and evaluating

of interventions to eliminate the nutritional problems in the country. In turn, this type of exercise will help

to improve the accuracy and quality of routinely collected data. The objectives of the nutrition information

system are as follows:

General objectives:

1. To develop a Nutrition Information System (NIS) with minimal additional inputs.Specific objectives:

1. To assess the nutritional status using a life style approach;

children under 5 years school children adolescents adults pregnant women

2. To develop indicators relevant to nutritional problems3. To identify trends in nutritional status and analyse associated factors4. To make recommendations regarding activities that should be undertaken to established a

surveillance system at MOH, district and provincial level.


6/52

NIS/MRI

6

CHAPTER 2

DEVELOPMENT OF NIS

It was decided to study the nutritional problems using a life style approach. The following steps were

adopted to collect information to develop the NIS, i.e.,

1. Identification of information to be included in the NIS2. Discussion with Experts3. Collection of available information4. Collection of information on children aged 5-14 years.

Figure 1

Conceptual Framework for the Causes of Malnutrition in Society

Outcomes

Immediate

causes

Underlying

Inadequate Education causes

Basic causes

Malnutrition and death

Inadequate dietary

intake

Disease

Inadequate

access to food

Insufficient healthservices and unhealthy

environment

Inadequate care formothers and children

Formal and non formal institutions

Political and ideolo ical su erstructure

Economic structure

Potential resources


7/52

NIS/MRI

7

2.1. Identification of information to be included in the NIS

Conceptual framework of the causes of malnutrition was used to facilitate the identification of data on

assessment and analysis of the determinants of malnutrition (UNICEF 1990). The framework is shown in

Figure 1. In this framework, casual factors and their interactions are shown at three mains societal levels-

immediate, underlying and basic.

The synergistic interaction between the two immediate causes, inadequate dietary intake and disease,

fuels a vicious cycle that accounts for much of the high morbidity and mortality. Three groups of

underlying factors contribute to inadequate dietary intake and infectious disease: household food

insecurity, inadequate maternal and childcare and poor health services, and an unhealthy environment.

These underlying causes are in turn underpinned by basic causes that relate to the amount, quality,

control and use of various resources (United Nation 1997). The following indicators were identified tocollect information on causal factors.

2.2. Discussion with Experts

Core-group was formulated with Public Health specialists, Academics and other specialists with nutrition

background (Annex-1). Series of discussion sessions were conducted to gather information. Major

nutritional problems in Sri Lanka were identified and the following areas were prioritised.

Low birth weight Protein energy malnutrition of children under 5 years and school children Iron deficiency anaemia throughout the life cycle Iodine deficiency among school children Vitamin A deficiency among children under five years

The following activities were identified under the design of the NIS.

development of indicators relevant to each nutrition problem to make decisions. needed data for selected information. sources of data,

administrative sources (data already being gathered routinely) household surveys

Responsibility of institutions.During the sessions of discussions the above activities were followed for the above-mentioned nutritional

problems as shown in Table 1.


8/52

NIS/MRI

8

Table 1

Identification of nutritional problems, indicators, source of data and responsibilities of

institutions using a lifecycle approach

Problem Definition of indicator Source of data Responsibility

Children under five years1.Low BirthWeight

% of new-borns below 2500g Monthly data fromFHB by DDHS area(H-509)

Monthly returnsfrom hospital

Birth weightSurveillance

D/FHB

Director/MS/DMO/MOIC/RMO

D(FHB)/MRI

II. Stunting(6-59 months)

% of children below -2SD from themedian of the NCHS/WHO height

for age reference population

Special surveys andsurveillance at

every 5 years

Existing researchdata/DHS/MRI/

NHSIII.Underweight(under 5years)

% of children below -2SD from themedian of the NCHS/WHO weightfor age reference population

% of children under 5 years whoattended clinics and below the 3rdcentile

Special surveys andsurveillance atevery 5 years

Monthly data fromFHB by DDHS area(H-509)

Existingresearchdata/DHS/MRI/NHS

FHBIV. Wasting(under 5

years)

% of children below -2SD from themedian of the NCHS/WHO weight

for height reference population

Special surveys andsurveillance at

every 5 years

Existing researchdata/DHS/MRI/

NHS

Primary school childrenV. Stunting atSchool entry( year 1, 4)

% of children below -2SD from themedian of the NCHS/WHO heightfor age reference population

Monthly data fromFHB by DDHS area(school healthreturn)


D/FHB

MRIVI. Wasting(year 1,4)

% of children below -2SD from themedian of the NCHS/WHO weightfor height reference population



D/FHB

MRIVII.Overweight(year 1,4)

% of children above +2SD fromthe median of the NCHS/WHOweight for height referencepopulation


D/FHB


9/52

NIS/MRI

9


MRI

AdolescentsVIII. Thinness

in adolescents(year 7)

% of adolescents below the 5th

percentile from the referencepopulation for under nutrition forBMI for age



D/FHB

MRI

IX. Overweightin adolescents

(year 7)

% of adolescents at and above85th percentile from the reference

population for BMI for age

Monthly data fromFHB by DDHS area

(school healthreturn)


D/FHB

MRI

Pregnant womenX.Underweight

% of pregnant women below 18.5of BMI at first trimester

Monthly data fromFHB by DDHS area

(H-509 return) Special surveys and

surveillance atevery 5 years

D/FHB

MRIXI. Weightgain inpregnancy

% of pregnant women with weightgain during the pregnancy

Monthly data fromFHB by DDHS area(H-509 returns to beincluded)


D/FHB

MRI AdultsXII. Dietrelated chronicdegenerativediseases

Rates of morbidity and mortality ofchronic degenerative diseases:cardiovascular disease, diabetes,obesity, some cancers:comparison with some infectiousdisease rates

Hospital data fromhealth bulletin

D/information

XIII.Underweight

% of adults below the 18.5 BMI Special surveysandsurveillance atevery 5 years

MRI


10/52

NIS/MRI

10

XIV.Overweight

% of adults above the 24.9 of BMI Special surveysandsurveillance atevery 5 years

MRI

XV. Changingdietary

patterns

1. Food availability by food groupsin the country.

2. Per capita daily energy intakefor selected food items by sector3. Contribution of each foodgroups to the overall calorie intakewith income

Food balancesheet

Socio-economicsurvey Socio-economic

survey

Censusand

statistics Central

Bank

CentralBank

Micro nutrient deficienciesXVI. Anaemia % of children with haemoglobin

below the cut-off value. Special surveys

andsurveillance atevery 5 years

MRI

XVII. Vitamin Adeficiency

% of children with the prevalenceof serum retinal mol/LMild =>0-=10-=20

Special surveysandsurveillance atevery 5 years

MRI

XVII.Iodinedeficiency-

1. % of children of 6-12 years ofage with urine iodine levels


11/52

NIS/MRI

11

infectious disease rates Health Bulletin MOHHouseholdfood security

dietary energy supply; food intake relative to need, Percent below poverty line,

Socio-economicsurvey

CentralBank

Inadequatematernal andchild care

Breast feeding (duration andpercentage);

Mean age of introduction ofcomplementary foods;

Usage of oral RehydrationFluids (ORT)

Health Bulletin/ H-509


H-509

MOH/FHB

MRI

FHBAccess tobasic health

services

Coverage of measlesvaccination,

Births attended by a trainedhealth staff,

H-509

H-509

FHB

FHB

Healthyenvironment

Availability of clean water, Availability of sanitary latrines

PHI sanitationrecord

PHI sanitationrecord

D/Environment/MOH

The identified indicators to assess nutritional problems, source of data and responsibilities of the

collection of data were finalised with Experts. Since information regarding to children less than 5 years is

available at the moment, it was decided to use secondary data as baseline information. To carry out the

school based study to collect information on children aged 5-18 years due to the importance of problems

in that group and lack of current data.

2.3. Collection of available information

Information was collected with regard to each indicator by identified data sources and literature review,

including reviews of "grey" or unpublished literature and by interview with key informants. Due to the

methodology adopted in the Demographic Health Survey (DHS), it was not possible to identify the

prevalence of nutritional problems and the determinants by districts or provinces. Therefore other

available studies were used.


12/52

NIS/MRI

12

The following data was available (routine and survey data):

Children under 5 years Adults Micro nutrient deficiencies Causes of malnutrition under 5 years

Following information is not available:

Primary school children Adolescence Pregnant women

Therefore simple method was adopted to collect information on primary school children and adolescence

at school level.

2.4. Collection of information on children aged 5-14 years

Information was collected cross-sectionaly in 7 districts of the country due to logistic reasons. The

districts were selected by considering the following factors:

High and low prevalence of stunting and wasting of children under 5 years for last 20 years Prevalence of stunting/ wasting/ underweight has not been changed much during the last 20

years.

Prevalence of Vitamin A deficiency in the area Prevalence of anaemia in the area Deficiency of iodine in the area Presence of representative data by district and Province.

The following districts were selected.

Anuradhapura, Polonnaruwa, Badulla, Moneragala, Colombo, Hambantota, Kurunagala.

2.4.1. Data collection

Data were collected among school children aged 5-14 years because 90% of children belonged to the

particular age group could easily met in the schools. The required sample size for each district was

calculated on the basis of the prevalence of underweight among children less than 5 years. This was 800

children from 5-14 year old age group giving a total sample size of 5600 for all 7 districts. The schools

were selected from a list of all schools in Sri Lanka that was provided by the Department of Education. A

multi-stage stratified sampling technique was used to identify the sample. During the first stage the

proportionate stratification was done to identify the number of schools in the urban and rural areas in


13/52

NIS/MRI

13

each district according to the population of children in selected age group. In the second stage, types of

schools were considered. During the third stage, required number of schools was identified using

population proportion to sampling technique. During the fourth stage of sampling, all classes of grade 1, 4

and 7 were listed out and one class from each grade was randomly selected from each school. Grade 1,4

and 7 was selected to study by considering the school health programme in the country to adopt that

data into the NIS in the future. All the children in each selected class were included in the assessment

nutritional status.

The following information was obtained:

1. Basic information: birthday and sex and other identifying information2. Biochemical assessment for anaemia3.

Measurement of height and weight

2.4.1.1. Basic information

All children in selected classes who had obtained the consent of their parents and were present on the

day of the study were identified as participants. A structured format was developed to obtain identification

data, age and sex of children in the selected classes. The information was obtained from the attendance

register and marked on the format by a member of the study team.

2.4.2.2. Biochemical assessment for anaemia

Sample of capillary blood for estimating haemoglobin was obtained from 10 children, selected at random

from each selected class (grade 1,4 and 7) in each school. Haemoglobin was assessed by Haemocue

method. A total of 30 haemoglobin from each school was estimated. The following procedure was used

to detect anaemia by using HaemoCue method: A finger-pricked drop of capillary blood was taken by

using a disposable lancet. The function of the HaemoCue photometer was checked on a daily basis by

measuring the control cuvette.

2.4.2.3. Measurement for height and weight

All the children in selected classes were measured for height and weight. Measurements were taken by

the field investigators who had been trained and standardised before the study. Height was recorded to

the nearest centimetre by using anthropometrics rod. The children were weighed with the use of an

electronic balance to the nearest 0.01kg after they removed their shoes and socks. The observer


14/52

NIS/MRI

14

variation was assessed by duplicating the measurement by the same observer and repeating the 10% by

the best investigator.

2.3.2. Field level activities

The field investigators, all of whom have previous experience in field research activities, were responsible

for all components of the study (Annex-2). Investigators were trained in testing the capillary blood

samples for haemoglobin content. All selected schools were informed about the study. The consent

forms were distributed to all children in the selected classes prior to the study to obtain the consent of the

parents/guardians. The schools were informed of the date of the visit. All fieldwork was completed during

a 6-month period, November 2001 - April 2002.

2.3.3. Collection of data in Colombo district:Five schools from urban sector were covered by the study team. Rural sector schools were not studied

due to the school vacation.


15/52

NIS/MRI

15

CHAPTER 3

Findings of the baseline information

A nutrition information system requires; correct assessment of the problem; an appropriate analysis of

the causes of the problem on a provincial or district basis; and the resources available to combat theproblem. Based on these causes of the problems and the resource analysis, action would then be taken

and the results, including the achievements of a particular desirable outcome, measured. This would in

turn provide an opportunity for further analysis and better action to improve the nutrition situation -"Triple

A cycle" (Asian Development Bank 1999).

3.1. Assessment of the problem

The results are presented according to the following order by considering the lifecycle approach: low birth

weight, protein energy malnutrition (PEM) of children under 5 years, nutritional problems among school

children, nutritional problems among adults, Vitamin A deficiency, iodine deficiency. This section includes

a presentation of prevalence and trends of the nutritional status.

3.1.1. LOW BIRTH WEIGHT

Most children are born with low birth weight and become increasingly malnourished. Figure 2 shows that

the highest low birth weight is in the Central Province and then in Uva Province. The lowest is in Western

Province. But it had declined in all the Provinces.

Figure 3 and 4 shows the geographical distribution of the prevalence of low birth weight. Annual health

bulletin provides the registrar General's data, which are originally taken from hospital statistics and not

validated, for districts. Therefore this data should be interpreted cautiously. WHO (1995) recommended,

Figure 2

Trends in prev alence of Low Birth Weight in Provi

of Sri Lanka, 1975-2000(Source: Annual Health Bulletin 1984-2000, Ministry

of Poli cy planning 1988/89)

0

10

20

30

40

50

60

70

80

1984 1988-89 1991 1992 1993 2000Year

%

Central

North central

Sabaragamuwa

Uva

Southern

North Western

Western

Eastern

Nothern


16/52

NIS/MRI

16

prevalence of >15% of LBW as the cut-off for triggering public health action. Therefore the arbitrary cut-

offs were used as =20% as low, moderate, high and very high prevalence of

LBW in the population. The very high prevalence was detected in NuwaraEliya, Badulla, Monaragala and

Batticaloe districts. Almost all the districts show the prevalence higher than 10%. When the data was

compared with the 1988/89, an improvement was detected in some districts like Polonnaruwa, Matale,

and Puttulum etc.

Figure 3 and 4

Prevalence of low birth weight by district, 1988-2000

(Source: Ministry of policy planning 1988/89 and Annual health bulletin 2000)

3.1.2. PROTEIN ENERGY MALNUTRITION OF CHILDREN UNDER 5 YEARS

Figure 5

Child malnutrition (0-4.99 years)

in Sri Lanka, 1975-2000

0

10

20

30

40

50

60

70

1975-76

1977-78

1980-82

1987

1993

1995-96

2000

Year

Percentagebelow

median

(-2SD)

Underweight

Stunting

Wasting


17/52

NIS/MRI

17

As shown in Figure 5, stunting among Sri Lankan children has improved from 49.9% to 13.5% since 1975

but wasting has not improved during this period, i.e. 13.9% to 14%. Though the underweight is a complex

index to interpret it has also declined from 57.3% to 29.4%.

There are wide variations in the prevalence of stunting and wasting among the different Provinces in Sri

Lanka, the Uva Province having the highest rate of stunting and the Western Province having the lowest.

But all the Provinces have shown a marked improvement (Figure 6). Wasting among children has

increased in Sabaragamuwa Province. But in all other Provinces it has gone up in 1988/89 and come

down to the 1980-82 level in 1995. There has been no improvement at all in the North Western Province

since 1980 (Figure 7).

Figure 7

Trends in prevalence of Child wasting (0-4.99 years) in

Provinces of Sri Lanka, 1980-2000

0

5

10

15

20

25

1980-82 1988-89 1995 Year

Percen

tage

be

lowme

dian

(-2SD)

Central

North central

Sabaragamuwa

Uva

Southern

North Western

Western

Figure 6

Trends in prevalence of Child stunting (0-4.99 years) in

Provinces of Sri Lanka, 1980-1995(Source:Ministry of policy planning 1980/2,1988/9 and MRI 1998

0

10

20

30

40

50

60

1980-82 1988-89 1995 Year

Percen

tage

be

low

me

dian

(-2SD)

Central

North central

Sabaragamuwa

Uva

Southern

North Western

Western


18/52

NIS/MRI

18

Figure 8 and 9

Prevalence of stunting among children less than 5 years by district, 1987-2001

(Source: Ministry of policy planning 1988/89 and MRI 2001-unpublished )

The prevalence of wasting and stunting by districts were mapped out to assess the problem at micro

level. The degree of stunting and wasting was classified as low, moderate, high and very high to assess

the severity of malnutrition in the provinces and districts (the classification currently used by WHO Global

database was taken). As the district data is not available after the year 1988/89 the unpublished data on

the anaemia status survey report was analysed by district to be used but this data are not representative

of district. Therefore this information should be interpreted cautiously. It is interesting to note that the

level of stunting ranges from low to high and that very high level of stunting is not detected at present.

NuwaraEliya district still shows a high level of stunting. The reason may be due to the fact that in this

district whose population consists of estate workers, infrastructure is lacking when compared to other

districts. Kandy, Badulla and Monaragala districts have a moderate degree of stunting and the rest of the

districts have a low degree of stunting. When these findings are compared with 1988/89 data, it shows a

tremendous improvement.

However, the geographical distribution of stunting and low birth weights by districts are compared (Figure

4 and 9), it showed somewhat similar distribution. Low birth rate may be a causal factor for the stunting.


19/52

NIS/MRI

19

Figure 10 and 11

Prevalence of wasting among children less than 5 years by district, 1987-2001 (Source: Ministry of

policy planning 1988/89 and MRI 2001-unpublished)

In 1988/9, most of the districts had a very high level of wasting except in 5 districts. At present there is a

marked improvement and only 6 districts still maintain a very high level of wasting. Gampaha district has

changed from a high degree of wasting to medium degree of wasting and Matale district has changed

from very high level to a low level of wasting during the last 13 years (this observation may be related to

low sample size in Matale district in 2001). Though the national level of wasting has not got changed, the

district level improvements are remarkable. At present, more concentration should be focussed on the

districts, which still maintain very high levels of wasting, i.e., Kurunagala, Anuradhapura, Polonnaruwa,

Kandy, Monaragala and Hambantota.

3.1.3. NUTRITIONAL PROBLEMS AMONG SCHOOL CHILDREN

The data were collected from 7687 school children in 7 districts. Two age groups were identified and

classified into groups, primary school children (5-9.9 years) and adolescents (10-14.9 years). Number

of children in each age group was 4876 (63.4%) and 2811 (36.6%).

3.1.3.1. UNDER NUTRITION

I. Primary school children

The nutritional status was assessed by calculating the wasting and stunting of children aged 5-9.9

years and it was graded according to WHO classification and shown in the Figure 12 and 13 to illustrate

the geographical distribution.


20/52

NIS/MRI

20

Figure 12 and 13

Prevalence of stunting and wasting among school children aged 5-9.9 yearsby districts, 2002

Badulla district has moderate degree of stunting and it is the highest rate reported in this school study.

All the other districts surveyed have mild degree of stunting. These findings are comparative with the

stunting rates among children under 5 years of age except in Monaragala district, which showed a

moderate degree of stunting prevalence among children less than 5 years (Figure 12). In that case it is

interesting to note that there is an improvement of stunting from pre-school to school children in

Monaragala district.

Figure 13 shows the wasting prevalence in the surveyed districts. A very high grade of wasting has

been found in Kurunagala, Monaragala and Hambantota districts according to the population

prevalence. All the other districts, which were studied, also have a high degree of wasting. A similar

pattern is observed when we compare this with the wasting prevalence among children less than 5

years. In Anuradhapura district of course, there is a difference. There is a shifting from very high

prevalence to high prevalence from pre-school to school (Figure 11).

II. Adolescents

When NCHS/WHO reference was applied to classify the under nutrition and over nutrition among

adolescents, 44.7% and 84.0% of records in the studied population was flagged at the age of 10 years

and 11 years respectively. Therefore the BMI-for-age-sex was taken as a reference and thinness was

calculated by districts and shown in Figure 14.


21/52

NIS/MRI

21

Figure 14Prevalence of thinness among schoolchildren aged 10-14.9 years by district, 2002

The proportion of the population with thinness was

classified by WHO (1995) as low, medium, high and

very high prevalence to classify the severity of the

thinness. It would also define a public health

problem and this classification is closely linked to

available resources for correcting problems, the

stability of the environment and government

priorities (Figure 14). Hambantota district has

shown a very high level of thinness and all the other

districts studied have indicated high level. It isinteresting to note that this observation is

comparative with the pattern observed among

primary school children except in Monaragala and Kurunagala districts. In these districts there is an

improvement from very high level to high level from primary school to adolescents. This finding

indicates that when children are close, at, or passing the growth spurt they have caught up the growth.

3.1.3.2. OVER NUTRITION

I. Primary school children and adolescents

Primary school children whose Wt/Ht is >2SD in the NCHS/WHO reference and the adolescents whose

BMI>=85th percentile in WHO 1995 reference, was classified as overweight children. Geographical

distribution is shown in Figure 15 and 16. The proportion of the school children with overweight was

classified by taking arbitrary cut-off points to reflect the distribution of overweight among children as

shown in Figure 15 and 16 (low, medium, high and very high prevalence). In this study it was found

that there is low prevalence in all the districts studied except in Colombo district. Figure 16 shows the

increasing pattern among adolescents. Colombo district has a very high level of overweight prevalence

among adolescents children. But it showed a medium prevalence with primary schoolchildren. Even

the Badulla and Polonnaruwa districts have increasing trends from low to high prevalence. This is a

situation to be aware of with the decreasing trend of under nutrition in the country.


22/52

NIS/MRI

22

Figure 15 and 16Prevalence of overweight among schoolchildren aged 5-9.9 years and 10-14.9 years

by district in year 2002

3.1.3.3. ANAEMIA

Anaemia was assessed by measuring haemoglobin levels of school children. Total number of children

tested for anaemia was 1448 and 766 from primary school children and adolescents respectively. Age

dependent haemoglobin levels were taken to detect anaemia by adjusting the altitude. The proportion of

the school children with anaemia was classified by taking WHO cut-off points to reflect the distribution of

anaemia among children as shown in Figure 17 and 18 (low, medium, high and very high prevalence).

Figure 17 and 18Prevalence of anaemia among schoolchildren aged 5-9.9 years and 10-14.9 years

by district in year 2002


23/52

NIS/MRI

23

Very high levels of anaemia were not seen in any district. A high degree of anaemia has been shown in

Anuradhpura and Kurunagala districts. Thalasaemia is more prevalent in these districts. When it comes

to the adolescent group Colombo district has a low level of anaemia and other districts have a medium

level of anaemia prevalence.

3.1.4. NUTRITIONAL PROBLEMS AMONG ADULTS

3.1.4.1. Diet related chronic degenerative diseases among adults

The most prominent chronic degenerative diseases - cardiovascular disease, cancer and diabetes

mellitus - are linked by unhealthy diet and physical inactivity. Actions to prevent these diseases should,

therefore, focus on controlling the risk factors in an integrated manner. Therefore the disease pattern and

causal factors are analysed under selected indicators.

3.1.4.1.i. Morbidity and mortality rates among major chronic degenerative diseases

There is an upward trend of Diabetes Mellitus, Hypertension and Ischaemic Heart disease among

hospital admissions and in contrast to that there is a downward trend in helminthiasis and vitamin

deficiencies and intestinal infections (Figure 19). This pattern clearly shows the double burden of

diseases in Sri Lanka. At one end diseases related to poverty and at the other end diseases due to

prosperity.

Figure 19Trends in Hospitalisation of selected disease

in Sri Lanka, 1975-2000( Source:Health bulletin 2000 )

0

200

400

600

800

1000

1200

1975 1980 1985 1990 1995 2000 Year

Casesper100,0

0

population

Intestinalinfec dis

Helminthiasis

Nutr. Defi.

Diabetes

Hypertension

IHD

(Exclude: Jaffna, Kilinochchi, Mullativu and Ampara Districts)


24/52

NIS/MRI

24

3.1.4.1.ii. Changing dietary patterns

The eating habits of people are changing. More people are eating out more frequently or eating foods

that are not nutritionally balanced. They are consuming more of animal fats, sugar and fried foods and

less of fresh fruits and vegetables (WHO 2001).

Food availability in Sri Lanka since last two decades clearly shows this changing pattern (Figure 20). The

availability is directly related to the consumption pattern of the population. The oils, fats, sugar and meat

availability has increased in contrast to the decreased trend of the availability of pulses, nuts. Vegetable

and fruit availability has not changed much during this period.

Figure 20

Changes in percapita availability of foo

(gms/day) in Sri Lanka, 1982-1999(Source: Food balance sheets 1982-1999)

0

100

200

300

400

500

600

700

800

900

1000

1982 1984 1991 1995 1997 1999 Year

Gms

/day

Oils & Fats

Milk

Fish

Eggs

Meat

Fruits

Vegetables

Pulses & Nuts

Sugar

Roots & TubersCereals

Figure 21

Contribution from urban, rural and estate sect

(% of deaths) from diseases of the circulator

system in 1991 in males and females(Source:Cardiovascular research in Sri Lanka 1998)

0

20

40

60

80

Urban Rural Estate Sector

%

Male

Female


25/52

NIS/MRI

25

The mortality rates due to diseases of the circulatory system by sector suggest a higher mortality rate

among urban population than among rural and estate population (Figure 21). When we compare this

finding with per capita daily energy intake for selected food items, it shows that the urban population

consumes more animal food like meat, fish, sugar and milk than rural and estate population (Figure 22).

Coconut consumption is highest among rural population. This findings support the study carried out

among Polynesian islanders who obtain 34-63% of their food energy from coconut and found vascular

diseases uncommon among them (Prior 1981). Though the vegetable is grown in the estate sector, the

vegetable consumption is lowest among the estate population.

Figure 23

Components of diet in re lation to income deci

of spending units(Source: Consumer finance and socio economic survey 1996-97)

0%

20%

40%

60%

80%

100%

1 2 3 4 5 6 7 8 910

Income deciles of spending units

%

ofenergy

Others

Carbohydrate

Animal Fat

Vegetable Fat

Figure 22

Per capita daily energy consumption of select

food items by sector(Source: Socio-economic finance sur vey 1996/97)

0%

20%

40%

60%

80%

100%

Urban Rural Estate Sector

%o

fenergy

Others

Vegetable

Meat,Fish,Milk

Sugar

Coconut

Wheat Flour andBread

Rice


26/52

NIS/MRI

26

When the contribution of each food group to the overall calorie intake with rising income shows a

marked variation (Figure 23). The spending units at the upper income deciles derived higher proportion

of animal fat compared to others. In contrast, the lower deciles derived more energy from vegetable fat.

Rice, bread and wheat flour accounted for the highest proportion of energy derived for all groups.

3.1.4.2. Overweight and obesity

Inactive life is attributed to high body mass index (BMI) and the high rate of overweight and obesity in

the society. The changing pattern of prevalence of overweight among males and females in different

age groups in urban areas is illustrated in Figure 24. Though the study methodologies were not

comparative, it showed the high prevalence of overweight among females than males. The prevalence

of overweight is more among the 40-49 year age group. From then the reducing trend of overweight

has observed. This is an alarming situation when compared with the increasing trend of non-communicable diseases. This is one of the issues to be addressed urgently.

Figure 24

Prevalence of overwe ight and obesity among males

females, 1993-2001(Source: MRI, Lipid profile study 1993 & MRI 2002)

0

5

10

15

20

25

30

35

40

45

50

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 >=60

Age groups

%

Male overweight

2001 male overweight

Female overweight

2001 female overweight

Male obese

2001 male obesity

Female obesity

2001 female obesity


27/52

NIS/MRI

27

3.1.4.3. Underweight

Figure 25

Prevalence of underweight among adults over 40 years of age

in different populations, 2001 (Jayatissa 2002-unpublished,n=720)

The prevalence of underweight is also high among adults especially in the rural population. Figure 25

shows that the proportion of underweight is decreasing with the urbanisation. There are no existing

programmes to address this problem.

3.1.5. VITAMIN A DEFICIENCY STATUS (VAD)

The clinical signs of VAD include night blindness, Bitots spots, corneal xerosis and corneal scars orulcers. The prevalence of clinical deficiency is estimated by combining night blindness and eye

changes, primarily Bitots spot to form a total Xerophthalmia prevalence (United Nation 2001). Clinical

VAD assessed by eye deficiency (Xerophthalmia) is considered a public health problem at more than

1% prevalence (Asian Development Bank 1999).

The trend in clinical VAD prevalence was assessed in Sri Lanka from 1975 to 1996. It has reduced from

1.1% in 1975 to 0.3% in 1987 and 0.8% in 1995/96. It showed there is an improvement of clinical VAD.

The provincial estimates from previous surveys since 1975 was compared (Table 1).

The improving trend is apparent, except in the Western Province. When the provincial trends are taken

into consideration, we can see that the clinical VAD is a public health problem in the Southern and the

Sabaragamuwa Provinces in 1995, but not in the whole country. It is noted that the sub clinical VAD is

increasing. Sub clinical VAD is defined as the prevalence of serum retinol concentration below 0.70

mmol/l (20 g/dl) minus the percentage of individuals with clinical VAD (ACC/SCN paper No.19).

28.6

11.29.4

16.3

0

5

10

15

20

25

30

35

Rural

Office

wo

rkers

Semi-

urban

Total

Population categories

underweight%


28/52

NIS/MRI

28

Table 1

Vitamin A deficiency: prevalence trends in children (6-70) months since 1975

PROVINCE CLINICAL SUB CLINICAL

1975 1995 1975 1995

Western0.9 1 - 23.3

Central1 0.5 - 21.8

North Central0.7 0.5 - 56.8

Southern1.8 1.3 - 41

Northern0.6 _ - _

Eastern1 _ - _

North western0.7 0.3 - 46.0

Uva0.9 0.0 - 35.0

Sabaragamuwa2 1.8 - 49.5

SRI LANKA 1.1 0.8 3.9 32.5

Sri Lanka has initiated the supplementation with high-dose Vitamin A capsules in the year 2000, but the

reports are not available on capsule coverage. Though the clinical deficiency was low in North Central

Province, the sub clinical deficiency was higher. The Sabaragamuwa Province has shown both clinical

and sub clinical deficiency. All the Provinces have shown a severe sub clinical VAD.

The estimated prevalence of clinical VAD in 1995 is 0.95% in South Asia and the sub clinical deficiency

is around 10 20% (Asian Development Bank 1999). It is interesting to note that the sub clinical

deficiency in Sri Lanka is higher than the estimates.


29/52

NIS/MRI

29

3.1.6. IODINE DEFICIENCY

Iodine deficiency control is being tackled in the country through salt iodisation, which is supported by

legislation. Three indicators were used to assess the magnitude of the problem and as the process

indicators, i.e. goitre rates among school children, median urinary iodine concentration among school

children and the percentage of households consumption of adequately iodised salt.

3.1.6.1. Goitre rates

The rate of goitres in school children aged 8-14 years is a convenient way to assess the iodine status of

a community. Figures 26 and 27 show the past and present distribution of goitre rates by districts. It

shows the decline of goitre rates in some districts and the increase in some districts namely

Anuradhapura and Polonnaruwa. But not a single district shows less than 5% of goitre rates, which is

the indicator to the elimination of iodine deficiency. The major cause for this is that the iodine content

varies very widely among manufacturers, wholesalers, and retailers and at household levels.

Figure 26 and 27

Prevalence of goitre by districts (Source: Fernando et al. 1989 and MRI 2001)

3.1.6.2. Median urinary iodine concentration

Figure 28 shows that the Badulla and Matara districts have mild iodine deficiency according to median

urinary iodine concentration, which indicates the most recent iodine nutritional status.


30/52

NIS/MRI

30

Figure 28: Prevalence of median urinary iodine concentration by districts

Figure 29: Percentage of households used the adequately iodised salt by district

(Source: MRI 2001)

3.1.6.3. Household consumption of adequately iodised salt

The percentage of households that use the adequately iodised salt is only below 50% in Badulla and 50 -

69% in Matara (Figure 29). This may be the cause of mild iodine deficiency in these districts. In the

districts, which have shown more than the adequate level in urine the percentage of households, which

use iodised salt, are less than 50% except in Polonnaruwa district. This may be due to high level of

mineral content in drinking water.


31/52

NIS/MRI

31

3.2. Appropriate analysis of the causes of the problem by provinces or districts

The results are presented only with the causes of protein energy malnutrition (PEM) of children less than

5 years. It includes the appropriate analysis of description of the causes of malnutrition.

3.2.1. CAUSESOFPROTEINENERGYMALNUTRITIONOFCHILDRENUNDER5YEARS

Conceptual framework of the causes of malnutrition was used to facilitate the assessment and analysis of

the causes of malnutrition (Figure 1). In this framework, casual factors and their interactions are shown at

three main societal levels-immediate, underlying and basic.

3.2.1.i. Immediate causes

The immediate causes of malnutrition are the inadequate dietary intake and disease.

3.2.1.i.a. Dietary intake: dietary energy consumption,

This was used as an indicator to assess the dietary intake of the population. National data on dietary

energy consumption by the sector is presented in Figure 30. Estate sector showed the highest intake of

energy but the activity levels are very high among them due to the nature of manual work involved.

However, the energy level has not reached the Recommended Dietary Allowances (RDA) of active male.

Rural sector has shown an improvement of energy intake from 1969-1997. Literature suggests that when

there is an inadequate dietary intake, it is not only the intake of energy and protein, which is low, but also

the intake of some micronutrients.

Figure 30

Trends in pe rcaput dietary energy consumptio

sector, 1969-97(source: Central Bank, 1998)

1500

1700

1900

2100

2300

2500

2700

2900

3100

3300

3500

1969/70 1978/79 1981/82 1996/97

Year

Kcal

URBAN

RURAL

ESTATE

RDA(sedentary male)

RDA(active male)

RDA (sedentaryfemale)

RDA (active female)


32/52

NIS/MRI

32

3.2.1.i.b. Diseases:

Diarrhoea and Acute Respiratory Infection (ARI) contribute significantly to the high prevalence of PEM.

There is an important relationship between infections and dietary intake. Therefore the following

indicators were assessed to determine the relationship.

infectious disease rates - Figure 31,

The infectious disease rate was assessed by using the hospital data on national basis because the

reliable district data was not available. The districts, which have major hospitals, have higher rates of

cases because the data provided by the hospital indoor morbidity mortality register is not validated

according to the residence. However, Figure 31 clearly showed that there is a decreasing trend in

hospital admissions with infectious diseases and that admissions due to nutritional deficiencies and

helminthiasis are negligible.

3.2.1.ii. Underlying causes

Household food insecurity, inadequate caring practices and inadequate access to basic health services,

together with an unhealthy environment, are the underlying causes of inadequate dietary intake and

diseases and consequently of malnutrition.

3.2.1.ii.a. Household food insecurity

This was assessed by per-capita food availability (measured in total energy) in the country as shown in

Figure 32. Per capita food availability has not got changed much during last 20 years. But the availability

of animal foods has increased a little during this period.

Figure 31

Trends in Hospitalisation of infectious disea

in Sri Lanka, 1975-2000

( Source: Annual Health Bulletin,2000)

0

100

200

300

400

500

600

700

800

900

1000

1975 1980 1985 1990 1995 2000

Year

Casesper

100

,000

popu

lation Intestinal infec

dis

Helminthiasis

Nutr. Defi.


33/52

NIS/MRI

33

Figure 32Change in per-captia food availability (in total energy) in Sri Lanka, 1982-1999

(Source: Sri Lanka food balance sheet 1982-1999)

Two other indicators were identified to analyse the household food insecurity, i.e., the percentage of poor

household and average per capita calories consumption for poor households. The geographical

distribution was also analysed (Figure 33 and 34).

Figure 33 and 34

Percentage of poor households by district and average per capita calories consumption for poor

households by district

(Source: Consumer Finance Survey 1999, statistical abstract, 2000)

Note: Those households spending more than 50%, of the expenditure on food and adult equivalent food expenditure is less

than Rs. 743 per adult per month (excluding non-food) are considered as poor households.

More than 40% of the population were categorised as poor households in Matale, Monaragala and

Ratnapura districts. It is interesting to note that the per capita calorie intake of the poor in these districts

0

500

1000

1500

2000

2500

1982 1984 1995 1997 1999

Year

C

alor

ies

/day

Vegetable

Animal


34/52

NIS/MRI

34

is between 1600-1699 except in Monaragala district. This calorie intake is not at all adequate for very

active manual workers who live in these districts. It is interesting to note that in the Colombo district the

per capita calorie intake is between 1500-1599 calories (the lowest intake reported in the country) in spite

of only less than 10% of the population being considered poor.

3.2.1.ii.b. Adequate care for children and mother

Caring practices constitute the most neglected determinant of young child malnutrition, but it is the least

satisfactory condition at present. Caring practices can be divided into four major components: (United

Nation 1997)

- Feeding practices, including breast-feeding and complementary feeding practices.- Hygiene practices, including personal, food and household hygiene.-

Home based health care, including ORT, early detection of illness and health seekingbehaviour.

- Psycological practices, including early childhood stimulation.The National data on exclusively breast-feeding pattern shows the proportion for infants in the age group

of (5-11) months was 55% in 2000. Seventy-five percents of mothers have provided their infants below

four months with only breast-feeding and 90% of children are breast-fed for more than one year.

However, the district data varies a lot (DHS 2001). In Sri Lanka, 60% of children of 4-6 months aged

were introduced complementary foods in 1994. But the data related to the quantity, quality and frequency

are also equally important and the data are lacking.

Very few localised studies were carried out about hygiene practices. Both households and personal

hygiene are very important aspects of care. This may be one explanation of the big difference in

malnutrition between districts.

The indicator to assess the home-based care is use of Oral Rehydration Therapy (ORT) by mothers. This

information is collected by the Public Health Midwife.

The above information related to caring practices were not available by district it was decided to assess

the situation by taking an indirect indicator as shown below.


35/52

NIS/MRI

35

I. Child and maternal mortality rates

Figure 35 shows that the child and maternal mortality rates had declined since 1945. At present it is at a

minimum level. Therefore the geographical distribution was assessed to detect the micro level problem.

Figure 36 and 37

Infant Mortality Rate (IMR) per 1000 live births by district from 1988-1997

(Source: Registrar General's Data from Statistical Abstract 2000)

Figure 35

Infant mortality (IMR), Neonatal mortality rate (N

and M aternal mortality rate (MMR) in Sri Lanka,1

2000(Source:Registrar general department, Annual health bull etin 1999)

0

20

40

60

80

100

120

140

160

180

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

1997

Year

per

live

births

NMRIMRMMR


36/52

NIS/MRI

36

Figure 38 and 39

Maternal Mortality Rate (MMR) per 10,000 live births by district from 1988-1996

(Source: Registrar General's Data from statistical abstract 2000)

Figure 36, 37, 38 and 39 show the infant mortality rate and maternal mortality rate respectively. IMR is

higher in Rathnapura, Nuwaraeliya, Kandy, Badulla, Anuradhapura, Mullativ and Kilinochchi than in other

district. MMR is highest among the Ampara, Mullative and Kilinochchi districts, which are war torn areas.

3.2.1.ii.c. Access to basic health services and a healthy environment

These are underlying determinants of young child malnutrition. Coverage of measles immunisation and

percentage of births attended to by a trained health staff are two indicators of the access to basic health

services.

I. Access to basic health services

In Sri Lanka the percentage of births attended to by a trained health staff is almost 99%. Figure 39 and

40 shows the coverage of measles immunisation in 1995-2000. The immunisation was initiated in 1985

and the coverage is above 95% in most of the districts. But Kandy district has a low coverage, which is

below 85%. While Vavuniya district, which is an area ravaged by war has a level about 80-89%.


37/52

NIS/MRI

37

Figure 40

Measles immunisation coverage by districts from 1995-2000

Coverage of measles immunisation and percentage

of births attended to by a trained health staff showed

the sufficient level of basic health services in all the

districts of Sri Lanka. However, these data do not

show anything about the quality of services provided.

II. Healthy environment

availability of clean water, availability of sanitary latrines

Figure 41, 42, 43 and 44

Availability of safe drinking water and adequate sanitary latrines by districts from 1981-2000

(Source: Census of population and housing 1981 from Annual Health Bulletin 1994-2000)


38/52

NIS/MRI

38

The data on water and sanitation are shown in Figure 41, 42, 43 and 44. While access to water has

improved significantly since 1981, access to sanitary facilities is still very low.

3.2.1.iii. Basic causes

Education and information are crucial in determining how resources are used.

3.2.1.iii.a. Literacy rate

Sri Lanka has a very high rate of literacy as shown in Figure 45. There is no significant difference

between male and female literacy.

Figure 45

Literacy rate by sex in Sri Lanka from 1881-1996/7(Source: Annual Health Bulletin 1999, North and East not include

0

10

20

30

40

50

60

70

80

90

100

1881

1891

1901

1911

1921

1946

1953

1963

1971

1981

1994

1996/97

Year

%

Male

Female


39/52

NIS/MRI

39

Educational attainment is shown in Figure 46. About 40% attained education up to primary level in Uva,

North Central and Central provinces. About 30-35% have received an education up to secondary level

except in Western Province. This is also an important determinant during the nutrition education.

Figure 46

Educational attainment by Provinces 1996/97(Source: Central Bank of Sri Lanka 1996/97)

0

5

10

15

20

25

30

35

40

45

Weste

rnNW

P

South

ern NCP

Sabara

gamuw

aCe

ntral Uv

a

Provinces

%

No schooling

PrimarySecondary

Tertiary

3.2.1.iii.b. Maternal education

Female literacy is now widely recognised to be an important determinant of the health of the Nation.

Female literacy is lowest in the Uva Province and highest in the Western Province (Figure 48). Control of

resources at household level is as important as their availability in the household. In households, wherewomen control more resources, therefore the female education is an important determinant of child

malnutrition.

Figure 48

Literacy rate by sex by Provinces 1996/(Source: Central Bank of Sri Lanka 1996/97)

75

80

85

90

95

100

Weste

rnNW

P

South

ern NCP

Sabar

agamuwa

Centr

al Uva

Provinces

%

Male

Female


40/52

NIS/MRI

40

3.3. Resources available to combat the problem

Resources are required to fulfil the necessary conditions of food, health and care. Both the availability

and control of resources are important. Resources can be divided into human, economic and

organisational resources. This section is not dealt due to limited logistics.

The summary of findings is tabulated in the Table 3.

Table3

Summary findings of the NIS

Group Problem Findings

Pre-school

children

Low Birth Weight It is still a public health problem in Sri Lanka. Highest

prevalence was detected in NuwaraEliya, Badulla,

Monaragala and Batticaloe district. High proportions ofestate workers are residing in these districts. The data

screening should be done at district level to get more

accurate information.

Stunting NuwaraEliya district still shows a high level of stunting.

Kandy, Badulla and Monaragala district have moderate

degree of stunting and rest of districts have low degree of

stunting.

Wasting Though national level of wasting has not got changed, the

district level improvements are remarkable. At present,

the more concentration should be focussed on the

districts, which still maintain the very high levels of

wasting, i.e., Kurunagala, Anuradhapura, Polonnaruwa,

Kandy, Monaragala and Hambantota.

Primary-school

children

Stunting Badulla district has moderate degree of stunting and it is

the highest rate reported. All the other districts surveyed

are having mild degree of stunting. This finding is

comparative with the stunting rates among children under

5 years of age except in Monaragala district.

Wasting Very high grade of wasting has found in Kurunagala,

Monaragala and Hambantota districts. All the other

districts, which were studied also having high degree of


41/52

NIS/MRI

41

wasting. Similar type of pattern is observed when

compared with the wasting prevalence among children

less than 5 years except in Anuradhapura district, which

shows the shifting from very high prevalence to high

prevalence from pre-school to school.

Adolescents Thinness Hambantota district has shown a very high level of

thinness. All the other districts studied were indicated

high level, which is comparative with the pattern observed

among primary school children except in Monaragala and

Kurunagala districts, which shows the improvement from

very high level to high level from primary school to

adolescents. This finding indicates when the childrenclose, at or passing the growth spurt that they had

catches up the growth.

Overweight The increasing pattern was observed among adolescents.

Colombo district has a very high level that is shifted from

medium to very high levels with primary schoolchildren.

Even the Badulla and Polonnaruwa districts have

increasing trends from low to high prevalence. This is the

situation to be aware and alert with the decreasing trend

of under nutrition in the country.

Adults Diet related chronic

degenerative diseases

There is an upward trend of Diabetes Mellitus,

Hypertension and Ischaemic Heart disease among

hospital admissions and contrast to that the downward

trends of helminthiasis and vitamin deficiencies and

intestinal infections.

Changing dietary

patterns

The oils, fats, sugar and meat availability has increased in

contrast to the decreased trend of the availability of the

pulses, nuts. Urban population consumes more animal

food like meat, fish and milk than rural and estate

population.

Overweight and

obesity

The high prevalence of overweight among females than

males. The prevalence of overweight is more among the


42/52

NIS/MRI

42

40-49 years age groups and then the reducing trend has

observed. This is an alarming situation when compared

with the increasing trend of non-communicable diseases.

This is one of the issues to be addressed urgently.

Underweight The prevalence of underweight is also high among adults

especially in the rural population. There are no existing

programmes to address this problem.

Vitamin A deficiency Sri Lanka has initiated the supplementation with high-

dose Vitamin A capsules in year 2000, but the reports are

not available on capsule coverage. Though the clinical

deficiency is low in North Central Province, the sub

clinical deficiency was higher. Sabaragamuwa Provincehas shown both clinical and sub clinical deficiency. All the

Provinces had shown a severe sub clinical VAD.

Iodine deficiency Sri Lanka has shown a tremendous improvement towards

the elimination of iodine deficiency through the salt

iodisation programme. Moderate degree of goitre

prevalence has detected in the country. The major cause

for this is that the iodine content varies very widely among

manufacturers, wholesalers, and retailers and at

household levels. Quality control and monitoring of salt

iodine levels are the priority. To reduce the level of iodine

in salt at household and production sites should be

concerned.

Causes of protein

energy malnutrition of

children under 5 years

1. Estate sector showed the highest intake of energy.However, the energy level has not reached the

Recommended Dietary Allowances (RDA) of active

male.

2. There is a decreasing trend in hospital admissionswith infectious diseases and the admissions due to

nutritional deficiencies and helminthiasis are

negligible.

3. Per capita food availability has not got changed much


43/52

NIS/MRI

43

during last 20 years. But the availability of animal

foods has increased a little during this period.

4. More than 40% of the population were categorised aspoor households in Matale, Monaragala and

Ratnapura districts.

5. Per capita calorie intake of the poor in these districtsis between 1600-1699 except in Monaragala district.

This calorie intake is not at all adequate for very

active manual workers who live in these districts.

6. In the Colombo district the per capita calorie intake isbetween 1500-1599 calories (the lowest intake

reported in the country) in spite of only less than 10%of the population being considered poor.

7. Data related to the quantity, quality and frequency ofcomplementary feeding is lacking.

8. While access to water has improved significantlysince 1981, access to sanitary facilities is still very

low.

9. Female literacy is lowest in the Uva Province andhighest in the Western Province.


44/52

NIS/MRI

44

CHAPTER 4

Establishment of NIS and use of information

Mock and Mason stated in 1999, Nutrition information systems are an essential component of national

investment programmes aimed at reducing the incidence and prevalence of malnutrition in Asia (Asian

Development Bank 1999). The analysis presented in Chapter 3 uses the UNICEF conceptual framework

to develop the NIS across Provinces and districts and it explores relationships, especially between

immediate, underlying and basic causes and malnutrition.

The last 10-12 years data was used to develop this information system. This clearly shows that routinely

collected data can be used to gather information for following indicators:

Infants and preschool children: Low Birth Weight Underweight

School children Stunting (year 1, 4) Wasting (year 1,4) Overweight (year 1,4)

Adolescence Thinness (year 7) Overweight (year 7)

Pregnant women Underweight

Adults Diet related chronic degenerative diseases

Causes of malnutrition under 5 years Inadequate maternal and child care Access to basic health services Healthy environment

Sri Lanka has routine on-going data collection by the Public Health Midwives (PHM) and Public Health

Inspectors (PHI) and sends to the Medical Officer of Health (MOH) monthly or quarterly to compile. Data

related to the above indicators, which were used to build up the NIS could be collected from PHM or PHI

level. Some of the data are already collecting to use for Maternal and Child Health activities, i.e., Growth


45/52

NIS/MRI

45

monitoring data (number of under weight children), number of low birth weight children, number of infant

deaths, number of neonatal deaths, number of maternal deaths, breast feeding, measles immunisation

coverage, percentages of births attended by a trained health staff, safe drinking water, adequate sanitary

facilities etc. By building the NIS from these data will enhance the quality and use of routine data by the

data collectors themselves.

In general, the approaches should be explored to strengthen these data sources whereverpossible to join into the system.

Attempt should be made to obtain comparable data from other surveys and studies e.g. DHS In Sri Lanka

Demographic and Health Survey tend to collect detailed information on population and health, socio-

economic status and household food access etc. but it was designed to collect the information onEcological Zone basis. Therefore this information is not possible to use by Provincial or district's policy

makers. In addition to this survey income and expenditure survey is going on every 10 yearly by Central

Bank of Sri Lanka. Medical Research Institute has undertaken the nationally representative surveys on

Iodine, Anaemia and Vitamin A. National sample surveys are necessary to build up the Project's nutrition

information strategy, preferably within five-year intervals. Therefore NIS will help the comparability across

districts and Provinces quarterly or yearly.

Changing of methodological issues in DHS survey to collect data by Provinces. This can validatewith routinely collected information to facilitate accurate reporting. It is a big assert to the

decision makers.

Policymaking requires information that addresses causality, and that demonstrates the consequences of

various policy options to policymakers (Asian Development Bank 1999). Prevalence and causes of

malnutrition in districts varied. It is important to prioritise the causes accordingly. Then the interventions

varied from district to district. NIS will directly support to identify the priorities on district basis. Then it is

easy for policy makers to deviate from the common policies relevant to nutrition like food subsidies and

poverty alleviation programme. The following issues were highlighted in the analysis which can be used

during the policy decisions:


46/52

NIS/MRI

46

The universal availability of drinking water and sanitary toilets to all households should beensured because it was found lacking in most districts. It will help to reduce of malnutrition in

children linked with water-born infections.

Female education should be upgraded in Uva and Central province to facilitate the nutritioneducation and essential childcare support.

Since per capita calorie consumption is very low in poor households of Colombo district,targeting of nutrition interventions should be carried out to reach children from those households.

Associated problems like food security; caring practice data should be linked to the routineinformation collection by adding the identified indicators to the system.

Awareness should be created among urban sector people the high consumption of meat andsugar may relate to cardiovascular disease morbidity.

Screening of adult population after 40 years of aged is important due to increase overweightprevalence from 35 years and obesity since 55 years, this may be linked to well women clinic

with the concept of upgrading family health. This may be related to rising level of non-

communicable diseases.

The absence of data for evaluation of nutrition and community based programmes, is a major constraint

to the design of Provincial or district programmes. This is true in the area of under nutrition reduction, low

birth weight reduction, anaemia and care of young children. NIS will address this information gap, which

is a priority.

An important information tool, which is used in this NIS, is Geographical Information system. In Chapter

3, most of the information is mapped out by districts to detect the problem and determinants. Same

system can be extended to MOH and PHM areas because the maps and geographical boundaries are

already available. It can be done manually or if the resources are available by using the computer.

Programme planners, policy makers and Funding agents can use the mapping and analytical products

regularly for programme design and implementation.

Establishment of the NIS and the regular mapping of the prevalence of malnutrition at PHM, PHI,MOH, DPDHS and PDHS level should be done. Following indicators can be used at each level.

PHM level:

Infants and preschool children: Low Birth Weight


47/52

NIS/MRI

47

Underweight Pregnant women

Underweight Causes of malnutrition under 5 years

Inadequate maternal and child care Access to basic health services

PHI level:



Causes of malnutrition under 5 years Healthy environment

MOH level:

Infants and preschool children:

Low Birth Weight Underweight




Causes of malnutrition under 5 years Inadequate maternal and child care Access to basic health services Healthy environment


48/52

NIS/MRI

48

DPDHS level:

Infants and preschool children: Low Birth Weight Underweight




Adults Diet related chronic degenerative diseases

Causes of malnutrition under 5 years Inadequate maternal and child care Access to basic health services

Healthy environmentMaps should be up-dated periodically (quarterly, annually) to identify the areas representing pockets of

severely malnutrition in children less than 5 years and school children and nutrition programmes should

be targeted on such areas.

To complete the process of Triple A cycle, dissemination of information generated from NIS to policy

makers by a Newsletter or bulletin quarterly is needed. Then information can be use to evaluation of

programmes. The evaluations of impact of nutrition interventions are required to identify the gaps.

However, evaluation research is the weakest element of nutrition information strategies in Asia and

elsewhere. It is unwise to assume that well-established interventions are always contributing to reducing

deficiency, especially as circumstances change, and light of the growing knowledge of interactions

among nutritional deficiencies and the complexity of human biochemistry (Asian Development Bank

1999). Evaluation designs can be developed through NIS by MOH, District, Provincial and National level

yearly.


49/52

NIS/MRI

49

CHAPTER 5

REFERENCES

1. Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;2000.2. Ministry of Health Highways and Social Services, Project Proposal for the Nutrition component-

World Bank assisted Sri Lanka health services development project;1995

3. UNICEF. Strategy for improving nutrition of children and women in developing countries, UnitedNations Children's Fund, New York, USA:1990.

4. World Health Organisation, Physical status: The use and interpretation of anthropometry - Report ofa WHO Expert Committee, WHO Technical Report series 854, Geneva;1995.

5. Asian Development Bank, Asian Development Review- Studies of Asian and Pacific EconomicIssues,17(1,2);1999.

6. World Health Organisation, Global database for malnutrition among children under 5 years, 2002.7. Sri Lanka Demographic and Health Survey, Department of Census and Statistics;20018. Ministry of Policy Planning and Implementation, Nutritional status survey report, Nutrition and

Janasaviya Division;1980/2

9. Ministry of Policy planning 1988/910.Medical Research Institute, Vitamin A deficiency status of children Sri Lanka 1995/6, A survey report,

Ministry of Health and Indigenous Medicine;1998.

11.Medical Research Institute, Anaemia status report in Sri Lanka, unpublished;2002

12.Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;199113. Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;199214.Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;199315.Annual Health Bulletin, Ministry of Health, Planning unit, Sri Lanka;1999.16.ACC/SCN,. ACC/SCN Symposium Report. UN Sub-committee on Nutrition. Nutrition policy paper

#19; 2001.

17.Prior IA, Davidson F, Salmond CE, Czochanska Z. Cholesterol coconut and diet in Polynesian atollsa natural experiment tye Pukapuka and Tohaleau island studies. American Journal of Clinical

Nutrition; 1981;32:1552-1561.

18.Mendis S. Cardiovascular researches in Sri Lanka. Review and Bibliography (1905-1998). Ministry ofHealth, Colombo, Sri Lanka; 1998.

19.World Health Organisation. Non communicable diseases prevention and management. South-EastAsia Region; 2001.


50/52

NIS/MRI

50

20.Department of census and statistics. Statistical Abstract of the Democratic Socialist Republic of SriLanka, Sri Lanka Food balance sheet 1982-1984, Ministry of Plan implementation; 1985.

21.Department of census and statistics. Statistical Abstract of the Democratic Socialist Republic of SriLanka, Food balance sheet, Ministry of Finance and planning; 1997.

22.Department of census and statistics. Statistical Abstract. Ministry of Finance and planning Sri Lanka;2000.

23.ACC/SCN, Nutrition and Poverty. ACC/SCN Symposium Report. UN Sub-committee on Nutrition.Nutrition policy paper #16; November: 1997.

24.Central Bank of Sri Lanka, Socio-economic and Finances survey-1996/7;1998.25.Fernando MA, Balasuriya S, Herath KB, Katugampola S, Endemic Goitre in Sri Lanka, Asia Pacific

Journal of Public Health,3(1);1989

26.Medical Research Institute, Iodine deficiency status in Sri Lanka 2000/1, Survey Report, Ministry ofHealth;2001.


51/52

NIS/MRI

51

ANNEX-1

MEMBERS OF THE CORE-GROUP

1. Dr. Aberra Bekale - Head, Nutrition and Estate programme, UNICEF2. Mrs. Soma De Silva - Ex-Head, Evaluation and statistics unit, UNICEF3. Prof. D.N. Fernando - Professor of Community Medicine, Faculty of Medicine, Colombo.4. Dr. H.M. Fernando - Deputy Director General of Public Health Services, Department of health5. Dr. S.A.P. Gnanissara - Ex-Deputy Director General (ET&R), Department of health6. Dr. C.D. Gunaratne - Director Nutrition, Department of health7. Dr. V. Karunaratna - Director, Family Health Bureau8. Dr. Nynt Nynt Yi - Ex-Head, Nutrition and Estate programme9. Dr. S. Manikkarajha - Ex-Director, Estate and Urban health, Department of health10. Dr. C. Piyasena - Head, Nutrition Department, Medical Research Institute11. Prof. L. Rajapaksa - Associate Professor of Comm. Medicine, Faculty of Medicine, Colombo.12. Mr. N. Sumanaratne - Director, Ministry of Plan Implementation13. Dr. Vidyasagara - Ex-Director, Family Health Bureau14. Dr. K.P. Wickramasuriya - Ex-Director, Family Health Bureau15. Prof. T.W. Wikramanayake - Emirates Professor of Biochemistry


52/52

NIS/MRI

52

ANNEX-2

Study Team

Dr. Renuka Jayatissa - Consultant Nutritionist (Principal Investigator)

Dr. C.L. Piyasena - Head

Dr. A.M.A.S.B. Mahamithawa - Medical officer

Dr. I. Warnakulasuriya - Medical officer

Mr. J.M.Ranbanda - Nutrition Assistant

Mr. K.D. Chandrathilaka - Public Health Inspector

Mr. A.P. Seneviratne - Public Health Inspector

Mr. H.K.T. Wijesiri - Public Health Inspector

Mr. H.N.P. Caldera - Public Health Inspector

Mr. P.V.N. Ravindra - Public Health Inspector

Mr. E.G.S. Kulasingha - Public Health Inspector

Mr. M.A.M.P.K. Marasingha - Public Health Inspector

Mr. W.A.P.I. Pieris - Public Health Inspector

Mr. J.S.Dean - Secretary

Laboratory team:

Mrs. T. Amarasena - Research Officer

Mrs. K.S.N. Jayaratne - Medical Laboratory Technologists

Mrs. B.Y. Gamage - Medical Laboratory Technologists

Miss. H. Kulathunga - Medical Laboratory Technologists

Mr. P. Gamage - Laboratory Orderly

Mrs. W. Polpitiya - Laboratory Orderly

Mrs. A.G. Sriyani - Labourer

nutrition information sri lanka

Documents