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close this bookFood and Nutrition Bulletin Volume 15, Number 3, 1993/1994 (UNU Food and Nutrition Bulletin, 1993/1994, 90 pages)
close this folderNutrition planning
close this folderNutrition indicators for development: Priority and intervention efforts
View the document(introductory text...)
View the documentAbstract
View the documentNutrition indicators for development
View the documentNutrition indicators in the Philippines

(introductory text...)

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

Abstract

Nutrition indicators are commonly used to measure the progress of development programmes and projects. They are used by planners and policy makers to establish baseline values, to focus attention on the problems of nutrition, and to identify development projects for nutritionally at-risk groups of the population. The selection and identification of nutrition indicators should be based on precise criteria: measurability, appropriateness, comprehensiveness, relevance, sensitivity, and impact orientation. The Philippines used five nutrition indicators in the update of the Philippine Development Plan, 1990-1992: percentage of preschool children with weight less than 75% of the standard weight for age, percentage of schoolchildren 7-10 years old with height less than 90% of standard height for age, percentage of schoolchildren 7-10 years old with weight less than 75% of standard weight for age, per capita energy intake, and percentage of households with energy intake less than 100% adequacy. These indicators were selected on the basis of their sensitivity, simplicity, and usefulness in appraising the effects of nutritional interventions and the ease of data collection.

Nutrition indicators for development

Efforts to correct malnutrition have traditionally relied on direct nutrition intervention programmes. However, limited success and the high costs of these programmes have restricted their use. Although they may be effective in preventing selected nutritional problems, the overall problem of energy and protein deficiencies among large population segments can be solved only through economic and social development. Failure to consider nutritional goals explicitly in development plans, strategies, projects, and policies may worsen the overall nutrition situation, despite improvements made by direct intervention programmes.

Including nutritional goals in development plans and strategies requires knowing the true condition of an individual, community, or country on the basis of information derived from nutrition indicators. These indicators should be available to planners for establishing baseline values and for focusing their attention on the problems affecting a population. With such data the planners and policy makers can identify development programmes and projects that will benefit the less fortunate, and monitor the progress of development projects in meeting this aim.

 

Selecting indicators

Nutrition indicators should be selected and identified on the basis of an organized and precise set of criteria.

The United Nations Research Institute for Social Development has presented the following five criteria [1] which can be used by any country:

  1. The availability or obtainability of acceptable data. This might seem quite obvious, but much effort has been spent in elaborating theoretical lists of ideal indicators for which reliable statistics cannot be found and for which no feasible method of data collection is offered or evident.
  2. Validity. An indicator should make sense conceptually by virtue of its composition, structure, and performance. That is, its value should be consistent with other data and with common sense. If it measures factors other than those intended (even if the unintended factors have an important impact), it will be of little value.
  3. Comparability of operational and theoretical definitions. Different operations to measure the same object, even with the same basic indicator, often yield different data for the same area or population at the same period. In some cases differences due to different operations may not be so great as to require discarding the data, but in other cases some data may have to be suppressed in order for the indicator to be used; otherwise, comparability may be compromised far beyond what is acceptable. For example, measurements of height made with different types of instruments can result in unreliable data; this may be suspected especially when percentages of stunting over the years appear questionable.
  4. Degree of association or correlation of a particular indicator with other development indicators. In principle, socio-economic indicators should be well correlated with one another.
  5. Balance among sectors and generally between socioeconomic and nutrition indicators. This criterion is relevant when overall measurement of development covering both social and economic sectors is a goal. This means avoiding unnecessary overlap and undue proliferation of indicators.

Another set of criteria for selecting critical key indicators was used in the 1987 Economic and Social Impact Analysis and Women in Development (ESIA/WID) project in the Philippines [2]:

  1. Measurability. The indicator must be capable of being expressed in terms of quantitative measures.
  2. Appropriateness. The indicator must be capable of measuring a specific attribute or characteristic for the purpose of determining the extent to which an objective has been obtained.
  3. Comprehensiveness. The indicator should incorporate as much information on a given area of concern as feasible.
  4. Relevance. The indicator should be responsive and relevant in its attempt to monitor existing policy objectives.
  5. Sensitivity. The indicator should reflect actual changes in absolute levels or trends related to the aspects of conditions implicit in the goals or areas of concern.
  6. Impact orientation. The key indicator measures final impact/outcome rather than inputs.

In the ESIA/WID project, indicators were categorized into two groups: key indicators, which meet all the six criteria given above, and supportive indicators, which satisfy the criteria on measurability and appropriateness.

The following five steps, which have been identified for selecting indicators relevant for analysing economic development, could be adopted in selecting nutrition indicators for any development effort: (1) compilation of initial variables after review of published statistical series, (2) elimination of those with insufficient data or conspicuous defects or that do not distinguish between developed and developing countries, (3) a second reduction of variables based on duplication, (4) a third reduction to a reservoir of indicators, and (5) a final selection of a set of core indicators.

 

FAO Indicators

In 1983 Dr. R. U. Quereshi, regional Food Policy and Nutrition Officer of the FAO Regional Office for Asia and the Pacific, convened a consultation of nutrition experts from the region which identified the following four nutritional measurements as indicators for development [3]: birth weights, heights and weights of children, dietary scores, and affordability of a survival ration. The corresponding variables were birth weights, weights for heights of children at age of school entry (i.e., at 6-7 years of age), 24-hour recall of food intake during the final year of primary school, and the cost of 1,600 kcal from the staple cereal, represented as a proportion of the average daily income in various regions of the country.

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

—————————————————————————————————————————
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
—————————————————————————————————————————
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
—————————————————————————————————————————
Flow
Household expenditures
Food expenditures
Food/nutrient composition
Home food production
Wage rates
—————————————————————————————————————————

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

 

Actual

Targets

1987

1988

1989

1990

1991

1992

Preschool children
< 75% standard wt/age (%)a

17.1

17.2b

16.8b

16.3

15.2

14.0

Schoolchildren 7-10 yrs
< 90% standard ht/age (%)a

12.7

12.3b

11.8b

11.3

10.8

10.3

< 75% standard wt/age (%)c

13.2b

12.2b

11.2b

10.3

9.4

8.4

Energy intake per capita (kcal)d

1,753

1,781b

1,799b

1,831

1,858

1,887

Households with energy intake
< 100% adequacy (%)e

69.2

67.3b

65.4b

63.4

61.5

59.6

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

 

Actual

Targets

 

1987

1988

1989

1990

1991

1992

Average annual change (%)

Nutrition intervention programme food assistance ('000s)

Moderately and severely underweight pre-schoolersa

2,533

1,716.2

1,764.3

581

486

435

- 9.20

Moderately and severely underweight school- childrena

2,546.2

2,422.4

2,405.5

1,349

1,454

1,386

0.91

Pregnant/lactating women

134

212.1

220.7

177

288

255

12.94

Others

2,498

1,180

1,680.5

404

404

404

0

Nutrition and nutrition-related health services ('000s)

Moderately and severely undernourished pre- schoolersb

2,869

5,834.8

8,870.8

929.2

740.4

907

- 0.80

School-childrenb

8,651

7,773.8

3,883.4

4,402

4,000

4,600

1.48

Pregnant/lactating women

2,537

1,694.1

2,064.4

291.6

400.4

351.3

6.41

Others

1,591

2,503.7

1,092.6

6,900

7,699.2

8,565

Incremental food production ('000s)

Schoolchildren

4,935

4,970

5,487

5,734

5,926

2.68

Households

660c

668c

675

683

693

0.88

Farmers/families

103

342.7

925.6

2,130

2,065

2,271

Others

1.7

24.2

241.4

Nutrition information and education ('000s)

Preschoolers

26.9

81

34

38

Schoolchildren

4.3b

4,925.7

209

7,160

7,465

7,665

2.30

Pregnant/lactating women

466

487.2

2,064.4

1,054

1,542

Others

2,041

4,420.4

996.4

440

440

440

0

Nutrition advocacy
Provincial governors

43c

75

75

75

0

City mayors

60'

60

60

60

0

Municipal mayors

1,532c

1,532

1,532

1,532

0

Barangay captains

330c

40,908

40,908

40,908

0

Legislators

224c

224

224

224

0

Personnel development

Barangay nutrition schloars     1,000c 1,000 1,000 1,000 0
Training participants/programme implementors

1,900

1,500e

10,228c

1,043

Others

10,900

12,000c

13,600

15,400

17,400

8.56

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

 

Actual

Targets

1987

1988

1989

1990

1991

1992

Average annual change (%)

Nutrition intervention programmes

PL480 commodities (metric tons) 77,415 57,873 16,675        
Vegetable nurseries established     300 542      
Home gardens established     667,400 675,000 683,000 693,000
Livestock distributed
swine   6,023 30,350 6,953 3,151 7,301
goats   5,846 23,957 2,752 3,928 3,951
poultry   13,579 64,526 21,402 32,739 39,287
other     64,956 62,590      
Fingerlings distributed     50,900 71,400 23,300 25,600

Nutrition surveillance

Local surveillance systems set upa   2 R   3 R 2 P  
Growth-monitoring charts distributed   15,000 12,000 13,000 15,000 16,000 7.17
Weighing scales distributed 1,084 1,625 2,192 2,000 2,000 2,000 0

Nutrition policy development

Policy formulation and analysis
National Nutrition Council governing board meetings   5 6 6 4 4 - 12.64
technical committee meetings   8 12 12 6 6 - 20.63
Expert panels/advisory groups organized   4 12 12 12 12 0
Technical support provided to congressional committeesb   2 2 OR OR    
Nutrition activities in multilevel development plans/programmes
Nutrition committees organized/revitalized   9,560 17,836 25,988 34,140 40,908 16.33
Action programmes in depressed municipalities supported   100 215 198 495 595

Nutrition communications

Regional nutrition conferences with local executives   8 5        
BNS kits developed     1,000 1,000 7,500 7,500
IE materials distributed   202,152 1,000 11,500 12,000 10,000 - 4.55
Posters distributed ('000s)   1,000 110 1,200 1,331 1,464 6.85

Personnel development

Barangay nutrition scholars 8,847 9,500 10,048 9,696 10,696 11,696 6.45
District/city nutrition programme coordinators 228 228 300 325 350 375 4.89
Provincial nutrition action officers 75 75 75 75 75 75 0
City nutrition action officers 60 60 60 60 60 60 0
Municipal nutrition action officers 1,532 1,532 1,532 1,532 1,532 1,532 0

Nutrition research and standards

Research studies conductedc   53 70 73      

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.