Lancet Series Update 2013

1. Lancet Series Update 2013 By Monica Muti National Nutrition Technical Update Meeting 05-06 August 2013 Kadoma Hotel

2. Maternal and Child Nutrition 1: Maternal and child undernutrition and overweight in low-income and middle-income countries

3. Aim of this paper Assess the prevalence of nutritional conditions and their health and development consequences • To reassess the problems of maternal and child under-nutrition • 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

4. 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.

5. Framework for action to achieve optimum fetal and child nutrition and development

6. 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

7. Maternal Nutrition • Prevalence of over weight (BMI ≥25 kg/m2) and obesity (BMI ≥30 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. Maternal and Child Nutrition 2 Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

15. 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

16. 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

17. 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

18. 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

19. 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%

20. 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

21. 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

22. 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

23. 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

24. 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