Causes, consequences, and epidemiology of maternal and child u ndernutrition GCHBS 6780, Class 4 Monday 28 Jan 2013

1. Causes, consequences, and epidemiology of maternal and child undernutrition GCHBS 6780, Class 4 Monday 28 Jan 2013

2. THE DOUBLE BURDEN OF MALNUTRITION consists of • Malnutrition in early life (especially first 1000 days), marked by growth restriction, e.g. as stunting, and can have long term effects, e.g. on cognitive development • This process of early malnutrition causes changes in normal growth, development, and physiology/metabolism, some of which are risk factors for later ill-health (metabolic syndrome, etc) • This contributes to – but is not necessarily a part of – the emerging epidemic of obesity and NCCDs in mid-life: nutrition is both a preceding and current risk factor – more focus is on current risks

4. Risk Factors 4

5. Pre-pregnancy—pregnancy (IUGR)—birth—early childhood (1000 days) - - - - - - mid-life risks Metabolic syndrome (Hypertension, CVD, stroke, diabetes) Obesity Biological, environmental and behavioural risks for metabolic syndrome, obesity, and related health issues Socio cultural Food processing Marketing Economics Built environment Behaviours Food supply (High glycemic index, saturated fats, sugary foods/drinks, etc) Access/poverty Exercise Disturbed homeostasis Appetite control dysfunction Insulin resistance/IGT Etc

6. Who is affected by malnutrition (resulting from undernutrition)? • Mortality • Malnutrition

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9. ● ▬ ● 2000s 1980s Change in regional estimates of low birth weight and underweight women (unweighted estimates with available data) 1980s to 2000s, showing incidence of low birth weight tends to move with prevalence of low BMI in women. Low birth weight and low BMI in women move together towards low levels of each 9

10. ● ▬ ● ▬ ● 2000s 1990s 1980s First 1000 days … Changes in regional estimates of low birth weight and underweight children,1980s to 2000s, the length of the lines indicates extent of improvement over the approximately 20 year period. Underweight prevalences and low birth weight move together towards 0% 10

11. The double burden of malnutrition Underweight vs obesity in women in 36 high-stunting burden countries* *Of these 36 countries, data on both underweight and obesity prevalence among adult females were available only for 24 countries Source: WHO Global Database on Child Growth and Malnutrition

12. UNICEF, 1999 12

13. Processes leading to malnutrition and its immediate consequences

21. Breastfeeding

24. The Bangladesh Miracle http://www.gapminder.org/video/gap-cast/gapcast-5---bangladesh-miracle.html or http://www.gapminder.org/ go to videos -- for ‘Bangladesh Miracle’

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26. Rakku’s story … Discuss: What were the causes of Rakku’s baby dying? 26

28. Global food supplies and hunger

29. World cereal production per person Sources: http://www.census.gov/ipc/www/idb/worldpop.html; http://faostat.fao.org/site/567/default.aspx#ancor; FAO 1993 for 1950-60. 29

30. Estimated numbers of people ‘hungry’, updated from 2009 FAO releases 30

31. Source: http://www.fao.org/es/ess/faostat/foodsecurity/Files/PrevalenceUndernourishment_en.xls; 31

32. Cycles

33. Virtuous cycle First generation

34. Virtuous cycle Intergenerational

35. Epidemiology – regional trends

36. Regional Trends in Malnutrition: the evolution of the global nutrition situation Results for the UN SCN 6th Report on the World Nutrition Situation High Level Meeting on Nutrition, 23-24 November 2009, Brussels J Mason and R Shrimpton Based on the work of: Lisa Saldanha, Bibi Al-Ibrahim, Emily Cercone, Linda Heron, Katie Robinette, and Amit Wadhwa in the Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine. 36

37. Summary of numbers of countries with child underweight changes improving, none, or deteriorating, from repeated national surveys with latest result >=2000. MDG rate

38. Figure U2. Associations between underweight and stunting, from survey results 1990-2007, by region. Stunting and underweight move together in Africa and Asia, but not in poor S. and C American countries where stunting is much higher. Africa Regression results for 3 regions together. Stunting = 20.502 + (0.894 * uwt) – 5.495 (dummy for Asia) – 14.261 (dummy for SC Amer/Caribb) + 1.036 (interaction: dummy for SC Amer/Caribb * uwt). All coefficients significant p=0.000; interaction for Asia NS when in model. N=232, adj R squ = 0.764. CS Amer Caribb Asia 38

39. Figure VA1. Trends in VAD (prevalence of serum retinol < 20 mcg/dl in children < 5yrs) Shouldn’t these rates be faster with high coverage of VAC distribution? (Do VACs affect VAD?) 39

40. Figure An1. Trends in anemia in non-pregnant women by region This seems the most intractable problem – a breakthrough is needed. (Fortify rice successfully?) 40

41. Figure I3. Predicted numbers of people (developing countries) with goitre if there were no iodized salt, compared with current estimate (with 68% iodized salt coverage). An estimated 2 billion people would have goitre if there were no iodized salt, compared with an estimated 0.7 billion with the current coverage of about 70%. 41

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45. Underweight prevalences from repeated national surveys (Selected transitioning countries) (WHO standards)

46. Underweight prevalences from repeated national surveys(Africa) (WHO standards)

47. Underweight prevalences from repeated national surveys E Africa (WHO standards)

48. The double burden of malnutrition Underweight vs obesity in women in 36 high-stunting burden countries* *Of these 36 countries, data on both underweight and obesity prevalence among adult females were available only for 24 countries Source: WHO Global Database on Child Growth and Malnutrition

50. Primary health care