Transcript Lancet Series Update

By Monica Muti
National Nutrition Technical Update Meeting
05-06 August 2013
Kadoma Hotel
Maternal and Child Nutrition 1:
Maternal and child undernutrition
and overweight in low-income and
middle-income countries
Aim of this paper
Assess the prevalence of nutritional conditions and their
health and development consequences
 To reassess the problems of maternal and child undernutrition
 To examine the growing problems of overweight and
obesity for women and children and their
consequences in low-income and middle-income
countries (LMICs).
 To assess national progress in nutrition programmes
 To assess international actions consistent with
previous recommendations
Framework
 shows the means to optimum fetal and child growth and
development, rather than the determinants of
undernutrition
 framework shows the dietary, behavioural, and health
determinants of optimum nutrition, growth, and
development
 and how they are affected by underlying food security,
caregiving resources, and environmental conditions, which
are in turn shaped by economic and social conditions,
national and global contexts, resources, and governance.
 This Series examines how these determinants can be
changed to enhance growth and development.
Framework for action to achieve optimum
fetal and child nutrition and development
Adolescent Nutrition
 1.2 billion adolescents (12-19years) in the world
 90% live in low to middle income countries(LMIC)
 Potential for catch up growth of stunted children??
 Adolescent fertility three times higher in LMICs than in high-
income countries.
 Pregnancies in adolescents
 higher risk of complications and mortality in mothers and children
 poorer birth outcomes
 slow and stunt a girl’s growth.
 In some countries, as many as half of adolescents are stunted,
11% thin, 5% obese
 High prevalence of anaemia
Maternal Nutrition
 Prevalence of over weight (BMI ≥25 kg/m2) and obesity (BMI ≥30
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kg/m2)
 rising in all regions (more than 40% in Africa by 2008)
Obese pregnant women
 four times more likely to develop gestational diabetes mellitus and
 two times more likely to develop pre-eclampsia
During labour and delivery, maternal obesity is associated with
 maternal death, haemorrhage, caesarean delivery, or infection;29–31
and a higher risk of neonatal and infant death
MUAC in pregnancy inversely associated with all cause mortality up to
42 days postpartum(one study)
Inverse association between maternal height and the risk of dystocia
(difficult labour)
Anaemia and Iron
 Among pregnant women with anaemia at baseline,
iron supplementation led to a 10・2 g/L increase in
haemoglobin (8・0 g/L in children)
 20% reduction in the risk of low birth weight
associated with antenatal supplementation with iron
alone or combined with folic acid
 Risk of death of children younger than 5 years reduced
by 34% when the mother consumed any iron-folic acid
supplements (Dibley et.al)
 protective effect greatest for deaths on the first day of
life
Vitamin A and Zinc
 Prevalence of night blindness in pregnant women
estimated to be 7・8%
 night blindness known to be associated with a four-
times higher odds of low serum retinol
 Maternal night blindness associated with increased
low birth weight and infant mortality
 trials of vitamin A in pregnancy not showed significant
effects on these outcomes
 17% of the world’s population at risk of zinc deficiency
 Based on analysis of national diets
Iodine and Folate
 28.5% of the world’s population estimated to be iodine
deficient
 Review of the effects of iodine supplementation in
deficient populations showed a small increase in birth
weight
 Substantial proportion of neural tube defects related
to inadequate consumption of folic acid around the
time of conception
 five trials of folic acid (a synthetic form of folate)
supplementation identified a 72% reduction in the risk
of neural tube defects
Childhood Nutrition
 Stunting - decreased from an estimated 40% in 1990,
to an estimated 26% in 2011
 Underweight - 16% ( 36% decreased from 1990)
 Wasting – 8% (11% decrease from 1990)
 Suboptimum growth shown to increase the risk of
death from infectious diseases in childhood
 Stunting and underweight with highest proportion of
attributed child deaths (14%)
 Overweight – 4% to 11% in Africa (projected to reach
11% in 2025)
 strong risk factor for adult obesity and its consequences
Determinants of childhood
stunting and overweight
 Promotion of appropriate complementary feeding
practices reduces the incidence of stunting
 Diarrhoea is the most important infectious disease
determinant of stunting of linear growth
 25% of stunting attributed to five previous episodes of
diarrhoea
 Optimum growth in the first 1000 days of life essential
for prevention of overweight
 rapid weight gains in the first 1000 days strongly
associated with adult lean mass
Conclusion to paper 1
 Evidence supports focus on pregnancy and the first 2 years of life
 More emphasis to the nutritional conditions
 in adolescence,
 at the time of conception, and
 during pregnancy, as important for maternal health and survival,
fetal growth and sub sequent early childhood survival, growth, and
development.
 Fetal growth restriction and poor growth early in infancy now
recognised as important determinants of neonatal and infant
mortality, stunting, and overweight and obesity in older children
and adults
 Preventive efforts should continue to focus on the 1000 days
 Therapeutic efforts should continue to target severe wasting.
Maternal and Child Nutrition 2
Evidence-based interventions for
improvement of maternal and child
nutrition: what can be done and at
what cost?
Background
 Update of interventions to address under-nutrition
and micronutrient deficiencies in women and children
 Current total of deaths in children younger than 5
years can be reduced by 15% if populations can access
ten evidence-based nutrition interventions at 90%
coverage
 About a fifth of the existing burden of stunting can be
averted using these approaches, if access is improved
in this way
Interventions to address
adolescent health and nutrition
 Reproductive health and family planning
interventions
 to reduce unwanted pregnancies
 to optimise age at first pregnancy
 Community and school-based education platforms
 To address micronutrient deficiencies
 To address emerging issues of overweight and obesity in
adolescents
Interventions in women of reproductive
age and during pregnancy
Folic acid supplementation
 Review of folic acid supplementation during
pregnancy
 Increase in mean birth weight
 79% reduction in incidence of megaloblastic anaemia
 Logistical challenges in reaching women of
reproductive age in the peri-conceptual period
 Fortification of cereals and other foods a possible
solution
Interventions in women of reproductive
age and during pregnancy
Iron or iron and folic acid supplementation
 WHO recommends daily iron supplementation during
pregnancy as part of the standard of care in populations at
risk of iron deficiency
Maternal multiple micronutrient supplementation
 Reduction in LBW, SGA, small effect on preterm births
 Potential for replacement of iron-folate supplements in
pregnancy in populations at risk
Maternal calcium supplementation
 shown to reduce maternal hypertensive disorders and
preterm birth
Interventions in women of reproductive
age and during pregnancy
Maternal iodine supplementation or fortification
 Iodised salt use the most cost-effective way to avert
deficiency
Addressing maternal wasting and food insecurity
with balanced energy and protein
supplementation
 Balanced energy protein supplementation, providing
about 25% of the total energy supplement as protein
 Leads to increased birth weight by 73g and reduced risk
of SGA by 34%
Nutrition interventions in
neonates
 Delayed cord clamping
 Significant increase in newborn haemoglobin
 Higher serum ferritin concentration at 6 months of age
 Neonatal vitamin K administration
 Neonatal vitamin A supplementation
 Additional data needed before developing
recommendations
 Kangaroo mother care
Nutrition interventions in infants
and children
 Promotion of breastfeeding and supportive
strategies
 Early initiation, EBF to six months, continued BF to
24months or more - global progress both uneven and
suboptimal
 Education and counselling interventions important
 More needs to be done to assess innovations and
strategies to promote breast feeding in working women
 Promotion of dietary diversity and
complementary feeding
Nutrition interventions in infants
and children
 Vitamin A supplementation in children
 continues to be an effective intervention in children
aged 6–59 months in populations at risk of vitamin A
deficiency
 Iron supplementation in infants and children
 Multiple micronutrient supplementation in
children
 Preventive zinc supplementation in children
Disease prevention and
management
 Inpatient treatment for children with complicated
SAM
 Community-based care for uncomplicated SAM
 programmatic evidence supports use of RUTF for
community-based treatment
Conclusion
 Scaling up to 90% coverage associated with
 15% reduction in under five mortality
 Little effect on maternal mortality
 Mean 20.3% (range 11・1–28・9) reduction in stunting
 61・4% (35・7–72) reduction in severe wasting
 Interventions with the largest potential effect on
mortality in children younger than 5 years:
 Management of SAM
 Preventive zinc supplementation
 Promotion of breastfeeding