Public Health and Community Nutrition, NTN 2153

Childhood Malnutrition in Sri Lanka

Prevalence and trends

Public Health and Nutrition (NTN 2153)

Department of Applied Nutrition
Faculty of Livestock, Fisheries and Nutrition
Wayamba University of Sri Lanka
Makandura

Childhood Malnutrition in Sri Lanka

 Public Health and Community Nutrition, NTN 2153
Introduction

Sri Lanka is recognized for achieving good health outcomes at low cost while it was a country
with low levels of per capita income. Sri Lanka is currently faced with a triple burden of
malnutrition; undernutrition, micronutrient deficiencies and overweight and obesity. It is seen that
these nutritional problems affect the whole life cycle and have intergenerational effects.
Malnutrition in children under five years of age (U-5) is widespread. Stunting, wasting and
underweight are all at levels identified by the WHO as being public health problems, wasting being
at the level of ‘very high’ while stunting is at a medium level of public health significance. Trends
in malnutrition have improved over time, but no progress has been made in the ten-year period
(2006- 2016) despite the decrease in overall poverty.

This document provides the details of the trends in nutrition and nutritional status in children aged
less than 5 years, its determinants, modifiable factors associated with stunting and wasting in
young children, district level direct nutrition (nutrition specific) and indirect nutrition (nutrition
sensitive) information, behaviours that may influence nutritional status among families in Sri
Lanka.

Figure 1 shows the conceptual framework of malnutrition developed by UNICEF.

Childhood Malnutrition in Sri Lanka

 Public Health and Community Nutrition, NTN 2153

Figure 1 : Conceptual framework of malnutrition

Undernutrition in children under 5 years old

National, district and sectoral level data on Protein Energy Malnutrition (PEM) are available from
a series of surveys and reports from 1975 to 2016. The following graph presents trends in child
PEM based on the WHO Global Database on Child Growth and Malnutrition (WHO, 2019). The
following figure shows (Figure 2) that although there has been a marked decline since 1975, and
there has been no change over the last decade.

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Figure 2 : Trend in underweight, stunting and wasting in Sri Lanka from 1975 to 2016

From 1975-76 to 2016 there has been a 64% reduction in underweight and a 65% decrease in
stunting. The prevalence of wasting fluctuated between 11.5% - 17.5% during the period 1975-
76 to 1993.

Table 1 provides the current prevalence of malnutrition and compares data from the Sri Lanka
Demographic and Health Survey 2006-07, National Food Security Assessment (NFSA 2009), The
National Nutrition and Micronutrient Survey (NNMS 2012) and Sri Lanka Demographic and
Health Survey 2016 (DHS 2016). All surveys studied children under 5 years of age (U5) and used
the WHO growth standards for comparison. However, there are differences in the areas surveyed
and the population groups: the DHS 2006 did not include the Northern Province while the DHS
2016 all provinces and districts. The NFSS (Nutrition and Food Security Assessment in Sri Lanka)
2009 randomly selected one district per province in the first stage of sampling and sampled the
Colombo district in two sub sections as Colombo Municipal Council area and Colombo district.

Childhood Malnutrition in Sri Lanka

 Public Health and Community Nutrition, NTN 2153
This sampling design does not provide reliable national estimates. The National Nutrition and
Micronutrient Survey (NNMS), 2012 used a sample of 300 households from each district and
national prevalence was estimated using weighted analysis.

Table 1 : Child nutrition data

Stunting
Assessment of child nutrition using the measurement of height-for-age is of crucial importance to
understand the health of children in the country. Data from the 2016 SLDHS revealed that 17%
of the children under age 5 in Sri Lanka are stunted, and 4 % are severely stunted.

Figure 3 provides the trends, projections and targets in the prevalence and number of U5 children
who are stunted. According to WHO tracking tool, the 2025 target for the prevalence of stunting
in U-5 children in Sri Lanka is 10.8%. However, the rate of stunting has remained relatively
unchanged from 2006 to 2016 in the range categorized as being of medium public health
significance.

Childhood Malnutrition in Sri Lanka

 Public Health and Community Nutrition, NTN 2153

Figure 3 : Trends projection and targets in the prevalence and number of children stunted
in Sri Lanka

Figure 4 : Trends in stunting of children under age 5 by districts, 2006 – 2016 (excluding
northern province

Childhood Malnutrition in Sri Lanka

 Public Health and Community Nutrition, NTN 2153

Figure 5 : Prevalence of stunting by districts, DHS 2016

Figure 6 : Prevalence of wasting by districts

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Factors associated with stunting
Stunting prevalence by age categories (Figure 7) shows that stunting,
- occurs during the first 1000 days of life; “the critical window of opportunity for optimum
growth”.
- is lowest among children whose mothers have a degree level education (12%) and three
times higher when mothers are uneducated (38%).
- is also two times higher among the poorest wealth quintile (25%) compared to the
wealthiest quintile (12%).
- shows an increasing trend from <6 months to 24-35 months but declines thereafter and is
not different between males and females (Male 17.9% Female 16.6%).

Figure 7 : Stunting prevalence in children by age categories

Wasting
Wasting and severe wasting appears to have remained static from 2006 to 2016. The 2016
prevalence of wasting is of very high public health significance (Figure 2). The 2012 data from
the NNMS shows an unusual feature; where the prevalence of wasting is seen to be higher than
the prevalence of stunting. Usually the prevalence of stunting which is a reflection of chronic
deprivation and repeated infections is higher than that of wasting which reflects acute weight loss
due to illness or short-term deprivation.
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Table 2 also contains information about weight-for-height to identify levels of wasting for children
under five years of age. The overall prevalence of wasting is 15 percent, with 3 percent identified
as severely wasted. Wasting is highest among children aged 0-5 months (19 %), while the lowest
prevalence is observed among those children aged 18-23 months (13 %). The level of education
of the mother is negatively associated with wasting. The birth interval of the child does not present
a clear pattern in relation to wasting.

Table 2 : Nutritional status of children (DHS, 2016)

Childhood Malnutrition in Sri Lanka

 Public Health and Community Nutrition, NTN 2153

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Childhood Malnutrition in Sri Lanka

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Table 3 : Nutritional status of children (NNMS, 2022)

Figure 8 : Trends in wasting in children under age 5 by district, 2006 - 2016

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Prevalence of wasting;
- decreases with maternal education. The prevalence of wasting in children whose mothers
have a degree level education is half (9%) that of children of mothers with no education
(18%).
- is high among children whose mothers have a low BMI (24.5%)
- is higher in the poorest quintile (17%) compared to the highest wealth quintile (10%).
- gradually declines from <6 months of age up to the end of the second year (<6 months:
19.4%, 18-23 months: 13.0%) and gradually increases thereafter (48-59 months:15.4%)
- has no sex difference (male 15.4% female 14.7%).

Figure 9 : Prevalence of wasting in children 0- 59 months by age categories

(DHS 2006, 2016)

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Figure 10 : Trends in nutritional status of children under 5 years, DHS surveys

Underweight
The 2016 DHS identified that 21 % of children as of low weight or underweight for their age, and
4 percent as severely underweight (Table 2).

Underweight percentages;
- increase with the age of the child, the highest level at 36-47 months of age (23 %).
- differences in the percentage of underweight children by sex
- associated with birth interval of the child
- associated with level of education of mothers
- differ according to the nutritional status of mother
- depends on wealth quintiles
- depends on place of residence
- associated with children living places. In the estate sector (30 %) has a much higher
prevalence of underweight than their counterparts in the urban and rural sectors (21 %, 16
%, respectively).
- differ across administrative districts. Children in Nuwara Eliya have the highest level of
underweight (30 %), followed by Mullaitivu (26 %), Anuradhapura (25%) and Moneragala
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(24 %). The lower levels of underweight children are observed in Jaffna (14 percent) and
in Colombo (15 %).

Figure 11 : Underweight by districts, DHS surveys (2006, 2016), excluding northern

province

Severe Acute Malnutrition

According to the 2016 DHS, the prevalence of severe acute malnutrition [SAM] (WHZ <-3) and
moderate acute malnutrition [MAM] (WHZ from <-2 to -3) in U-5 children were 3.0% and 12.1%
respectively (Figure 12).

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 Public Health and Community Nutrition, NTN 2153

Figure 12 : Prevalence of SAM, MAM, and overweight in children under 5, DHS 2016

Findings from NNMS 2022

Following figure shows the medium acute malnutrition, severe acute malnutrition in Sri Lanka
according to the NNMS, 2022.

Figure 13 : Prevalence of malnutrition and overnutrition among children of 6 – 59 months

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Childhood Malnutrition in Sri Lanka

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Figure14 : Wasting, stunting, underweight, overweight, and overall malnutrition by age

Figure 15 : Prevalence of stunting among children 6 – 59 months

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Figure 16 : Prevalence of underweight in children 6 – 69 months

Estate sector
The rate of stunting among under-five children was 36.4 percent, showing a decline from the
40.2 percent reported in the last DHS (2006-07) of the estate sector. Larger improvement is
evident for severe stunting (from 14.2% to 9.6%)

Figure 17 : Prevalence of stunting in children by age and sex

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 Public Health and Community Nutrition, NTN 2153
Underweight prevalence has, however, increased to 35.9 percent from 30.1 percent reported
in the DHS 2006-07. The burden is concentrated in the poorest quintile (41%), but is still
alarmingly high in the top quintile (31%).

Almost 16 percent of the estate sector children were wasted and suffered from acute malnutrition
(WHZ<-2SD); with 2.6 percent suffering from severe acute malnutrition (WHZ <-3SD). Wasting
increased by 2.5 percentage point compared to the 13.5 percent reported in the DHS 2006–07.

Based on the WHO classification of public health significance of malnutrition rates. the stunting
rate shows a ‘high’ public health significance while the wasting and underweight rates show a
‘very high’ public health significance.

Figure 18 : Prevalence of Wasting in Children 0–59 months Wasting by Age and Gender

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Table 3 : Public Health Significance of Child Undernutrition

Figure 19 : Summary of Nutritional status data of different stages of life based on different
survey dat
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NOTES

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References :
• Department of Census and Statistics (2017). Poverty indicators – Household Income and Expenditure
Survey 2016. Available at http://www.statistics.gov.lk/poverty/Poverty%20Indicators_2016.pdf
• Department of Census and Statistics (2018). Household Income and Expenditure Survey, 2016 (HIES
2016).
• Department of Census and Statistics, Ministry of National Policies and Economic Affairs Sri Lanka.
• Department of Census and Statistics and Ministry of Health, Nutrition and Indigenous Medicine. (2008).
Sri Lanka Demographic and Health Survey 2006-7 (DHS 2006).
• Department of Census and Statistics and Ministry of Health, Nutrition and Indigenous Medicine. (2017).
Sri Lanka Demographic and Health Survey 2016 (DHS 2016).
• Jayatissa, R., Gunathilaka, M. M., & Fernando, D. N. (2012b). National nutrition and micronutrient survey,
2012 (NNMS 2012). Medical Research Institute.
• Jayatissa, R., Perera A, Alwis N (2022). National nutrition and micronutrient survey, 2022, Medical
Research Institute
• Jayatissa, R., Gunathilaka, M.M. and Fernando, D.N. (2014) National Nutrition and Micronutrient Survey.
Part II: Iron, Zinc and calcium deficiency among children aged 6-59 months.
• WHO (2019) Childhood malnutrition in Sri Lanka: a road map for the last mile

Prepared by:

Dr. Thilanka K. Ranathunga

Senior Lecturer
Department of Applied Nutrition
Wayamba University of Sri Lanka

September 2023

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