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Nutrition indicators for development: Priority and intervention efforts

Ma. Patrocinio E. de Guzman and Wilma L. Molano

Nutrition indicators in the Philippines

The Philippine Food and Nutrition Program is one of the government's mechanisms to improve the quality of life of the country's people. One of its support strategies is nutrition surveillance, which is the regular generation, analysis, use, and dissemination of relevant information that will facilitate decision-making related to policies, programmes, and projects for nutrition improvement. Setting up the surveillance system involves identifying critical nutrition indicators. The characteristics of the indicators required for surveillance are determined by the causes of malnutrition, as expressed by the relationship among resources, flow, and nutrition and health outcomes.

The Food and Nutrition Surveillance System has identified three types of indicators: outcome, resource, and flow (table 1).

TABLE 1. Indicators by type

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Outcome
Weight for age (preschoolers)
Height and weight of school entrants
Proportionate mortality of children 1-4 years old
Infant death rate
Clinical protein-energy malnutrition
Mortality rate of third-degree cases
Goitre
Night blindness
Anaemia
Birth weight below 25 kg
Prices of critical food items
Prices of cash crops
Cash-crop production
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Resource
Village or community variables (ecological zone, altitude, topography, accessibility to roads and infrastructure,
cropping patterns, endemic diseases)
Household variables (occupation of household head and other income earners, landholding area, land tenure
status, education levels, use of technology, etc.)
Cropping pattern/farming system
Cultivated areas
Type of housing (income proxy)
Education (income proxy)
Percentage of barangays served by water-supply system
Sanitation (percentage of households with toilets)
Health services
Accessibility (distance to nearest urban centres)
Kilometres of road per square kilometre of cultivated land
Climate type and rainfall
Typhoon frequency
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Flow
Household expenditures
Food expenditures
Food/nutrient composition
Home food production
Wage rates
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Data from the Philippine Food and Nutrition Surveillance System, 1981.

Outcome indicators generally include nutrition status, infant and child mortality rates, morbidity, resources of socio-economic status, and environmental health.

Resource indicators examine the causes of malnutrition and describe different population groups by, for example, agro-ecological zone, type of farming system, cropping pattern, and access to services. Indicators measuring resources are useful both for setting targets and for formulating policies and programmes. They are applicable to villages, communities, and households.

Flow indicators account for the links between resources and outcome and include production, distribution, income, expenditure, and consumption information. This information is used to project future changes in food consumption. It is not essential for describing internal conditions at one time or for monitoring changes in outcome. Flow variables are often not included in nutrition surveillance systems because they are more difficult to collect accurately than resource or outcome data.

In the analysis of the results of the ESIA/WID project, nutrition indicators fall under the health sector, in the goal area of specific concern for the improvement of nutrition status. This concern is broken down into three issues: reduction in the prevalence of malnutrition among the vulnerable groups, reduction in the prevalence of specific nutrient deficiencies, and improvement of energy and protein intake. Under the first of these, two indicators are identified: the percentage decline in the proportion of underweight children to the total number of children of preschool age (0-6 years), and the proportion of newborn infants with low birth weight. Key indicators of the second issue are the prevalence of anaemia, goitre, and vitamin A deficiency. The third issue has one key indicator and one supportive indicator: per capita calorie and protein intake as percentages of the recommended dietary allowances, and the percentage sufficiency of the food and nutrient supply respectively. The Food and Nutrition Research Institute of the Department of Science and Technology is the source of information for three of these five indicators.

In the update of the Philippine Development Plan, 1990-1992 [4], the following impact indicators are identified under nutrition: the percentage of preschool children with weight less than 75% of the standard weight for age, the percentage of schoolchildren 7-10 years old with height less than 90% of the standard height for age, the percentage of schoolchildren 7-10 years old with weight less than 75% of the standard weight for age, per capita energy intake, and the percentage of households with energy intake of less than 100% of the adequacy level. All these were computed from data provided by the Food and Nutrition Research Institute [5].

Uses and users of nutrition indicators

The identification of nutrition indicators has vital implications for the assigned tasks and responsibilities of policy makers, development planners and workers, and academicians. The four basic uses of the indicators are as follows:

• As baseline and benchmark data. Nutrition indicators can reflect the present nutrition situation with which future data can be compared at the start of an intervention programme or project.
• For formulating nutrition targets—for example, for coming up with targets in the updating of the development plan [4].
• For planning social development programmes/ projects (for nutritionally at-risk groups). Government and non-government organizations use nutrition indicators in conceptualizing social development interventions. Consequently, the indicators become very important in implementing, monitoring, and evaluating the interventions.
• For formulating policy thrusts and strategies. As in the formulation of nutrition targets, nutrition indicators are used for the formulation of policy thrusts and strategies, as shown in the updating of the development plan [4].

Tables 2-4 show the nutrition targets for 19901992, using the development-plan indicators, and the actual figures for the indicators in 1987-1989.

TABLE 2. Philippine Development Plan (PDP) nutrition impact indicators, 1987-1989, and targets, 1990-1992

Sources: National Nutrition Council, DECS, Food and Nutrition Research Institute.
Targets for certain indicators were revised for 1990-1992 by the agencies concerned on the basis of projected resource availability.

1. Based on per capita energy intake targets and child mortality rates.
2. Estimate.
3. Targets obtained using the straight-line method with actual data from surveys conducted by DECS, School or Health and Nutrition Center, and the university of the Philippines College of Home Economics.
4. Based on per capita GNP and personal-consumption expenditure targets and actual energy intake data for 1976, 1978, 1982,1985, and 1987.
5. Targets for 1989-1992 based on an average annual decrease of 1.9% on the assumption that 50% of households will have an energy intake above the recommended level by 1997.

TABLE 3. PDP nutrition achievement indicators, 1987-1989, and targets, 1990-1992

Sources: National Nutrition Council, DECS, Food and Nutrition Research Institute.
Targets for certain indicators were revised for 1990-1992 by the agencies concerned on the basis of projected resource availability.

1. Reports for 1987-1989 included normal and mildly underweight.
2. Reports for 1987 and 1988 included normal and mildly underweight.
3. Estimate.
4. As of the second quarter of 1987 only.
5. As of the third quarter of 1988 only.

TABLE 4. PDP nutrition input indicators, 1987-1989, and targets, 1990-1992

Sources: National Nutrition Council, DECS, Food and Nutrition Research Institute.
Targets for certain indicators were revised for 1990-1992 by the agencies concerned on the basis of projected resource availability.

1. R = regions; P = provinces.
2. OR = on request.
3. To be conducted only up to 1990.

The Philippine Food and Nutrition Program uses nutrition and socio-economic indicators in its five nutrition intervention programmes. The National Nutrition Council, which coordinates the Food and Nutrition Program, also uses nutrition indicators in its Lalakas ang Katawang Sapat sa Sustansiya programme, an intensified nutrition-action programme formulated and managed by the community [6].

Problems encountered

Two problem areas in developing, identifying, and measuring indicators are conceptual and data problems. By and large, most development concepts, whether in nutrition, health, education, or agriculture, turn out to be so poorly defined that selecting specific indicators is difficult. Moreover, any statistical series proposed as an indicator must be assessed as to whether it really measures what it is intended to. It may fail to do so because of defective structure or because operational definitions are not consistent with theoretical definitions.

More difficult than conceptual problems are those related to the search for statistical series with adequate coverage. Many proposed indicators that are conceptually acceptable seriously lack the required data, or the available data may be unreliable, crudely estimated, or guessed rather than observed. The choice of a particular indicator depends, among other things, on the degree of tolerance of data imperfection that can be accepted.

The main reason for the general lack of good development indicators is that they are expensive to obtain. Lack of trained personnel and an underdeveloped infrastructure of transport and communication usually add to the difficulties. In developing countries, economic statistics are generally more advanced and available than social statistics. The tendency is to deal with social development through the use of economic statistics—for example, statistics on government expenditures on health and education instead of indicators of actual health or education. Economic indicators are also used as proxies for social measurement on the grounds of high correlation, and this is an equally unsatisfactory practice.

Possible solutions and recommendations

Nutrition indicators for children

Height for age is a good indicator of either past or chronic nutritional problems, with children who do not meet the standard height for age being classified as stunted. Weight for height, on the other hand, is an indicator of current nutrition status, with children with low weight for height being considered wasted. Weight for age is a less precise indicator because it does not differentiate between stunting and wasting. However, it is more commonly used for individual screening, growth monitoring, and community diagnosis.

Surveillance-system indicators

At present the National Nutrition Council uses an updated list of indicators in the Philippine Food and Nutrition Surveillance System that nutrition experts believe are available on a regular basis—namely, weight of schoolchildren, weight for height of schoolchildren, birth weight, morbidity, mortality, the price of staple foods, and climatic conditions. Although these are identifiable in the Philippine setting, they may vary from one country to another. For example, countries not frequently visited by strong typhoons or cyclones may not consider climatic events in their nutrition surveillance programme.

Critical indicators in the nutritional assessment of social development programmes

Among the many nutritional indicators available, four critical ones are most useful in assessing the impact of social development programmes and projects: the amount of staple food served per capita per day, the height for age of preschoolers (0-6 years old) and schoolchildren (7-10 years old), the weight for height of preschoolers, and the weight for age of both preschoolers and schoolchildren. These were selected on the basis of their sensitivity, simplicity, usefulness in approximating the effect of nutritional development, and ease of data collection.

These four indicators are important baseline benchmark data used by policy makers and planners in the Philippines to formulate nutrition targets and identify social development programmes and projects for the nutritionally at-risk population. The data on height for age, weight for height, and weight for age are available at the national and regional levels, and to a limited extent at the provincial level. The Food and Nutrition Research Institute gathers this vital information every two years. Policy makers, planners, and other interested individuals are therefore assured of regular results for these three indicators.

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