Knowledge &Research gaps in policy and programming for maternal infant and young child nutrition
Florence M. Turyashemererwa Lecturer- Makerere University Nutrition Consultant -WHO Researcher-Nutrition Innovation Lab Africa I will start this presentation with a brief overview of the global nutrition challenges affecting mothers and children using selected indicators 159 million children stunted in 2014
No of children affected(millions) Prevalence ( %) Recently the worlds top scientists identified a more sensitive indicator of nutritional status, based on the height for age of children under 5.A stunted child has an immediatehigher risk for communicable diseases and a longer term higher risk of chronic diseases; a stunted child does not develop in the same way as a normally growing child and in the long term has less professional opportunities. In 2014 ,159 million children (26%) under 5 were stunted, approximately one child out of three. Source: UNICEF, WHO and the World Bank Joint Child malnutrition estimates Where are the stunted children?
Stunting is highly prvalent in sub-saharan Africa and in South Asia. A large number of stunted children live in south Asia and about 40 countries are home to 90% of the world stunted children. 20 of these are in sub sharan Africa. 50 million wasted children in 2014
Prevalence ( %) No of children affected(millions) 8% global prevalence of wasting 3% global prevalence of severe wasting Acute malnutrition is intimately associated to chronic malnutrition. In 2014 acute malnutrition was present in 50 million children, of children under 5. Out of them, 16 million were affected by the most severe and life threatening form of wasting. Source: UNICEF, WHO and the World Bank Joint Child malnutrition estimates Where is acute malnutrition concentrated?
This slide shows the prevalence of acute malnutrition in diffrent world regions. When the blue diamond is in the green area the prevalence is lower than the 5% indicated by the WHA as a target to achieve. Other colours indicate the presence of a public health problem of increasing magnitude. Middle (10%)and Northern (13%) are the worst affected in Africa Source: UNICEF, WHO and the World Bank Joint Child malnutrition estimates Over 270 million children have anemia
A second form of malnutrition, linked to the inadequate intake of vitamins and mineralsThe condition with the highest prevalence is anemia. It has also been named the hidden hunger,as its impact Anemia also affects over 270 million children under 5. Early childhood anemia is associated with impaired cognitive development. South Asia is the most affected on the global scale. In Africa, Centra and West Africa followed by East Africa are worst affected. Source : Stevens et al. Lancet Glob Health 2013; 1: e1625 496 million non pregnant and 32 million pregnant women with anemia
The impact of anemia on women is greater on their own health as anemia affects womens working capacity, wellbeing and mortaltiy. Anemia also affectsthe health of their offspring. Anemia is due to multiple causes, including birth spacing, malaria and other infectious diseases. A large proportion of anemias approximately half are due to iron deficiency. In 2011 approximately 530 million women were anemic. Source : Stevens et al. Lancet Glob Health 2013; 1: e1625 41 million children are overweight
No of children affected(millions) Prevalence ( %) The third from of malnutrition, that has started to be recognised globally is overweight. Overweight was thought to be an issue only for high income countries and populations, and an issue for middle aged men. We can now say that overweight is almost ubiquitous, starts early in life and is rapidly increasing. In million children before age 5 were overweight. 30 million were in lower middle income countries and 6 million in low income countries Source: UNICEF, WHO and the World Bank Joint Child malnutrition estimates The double burden of malnutrition
This graph shows even better the coexistence of the two conditions in the same country. In South Africa, for example, over 40% of women is obese, the more severe condition, and 10% is underweight. The reverse happens in Bangladesh, where over 40% of the women is underweight and 5% obese. Conceptual Framework to achieve optimal fetal growth and development
conceptual framework, taken from the Lancet series of 2013 is a means to optimal fetal growth and development. The framework shows how dietary, behavioural and health factors are affected by underlying food security, caregiving resources and environment. In turn these are affected by economic social conditions and factors of governance. Acceleration of progress in nutrition will require coupling nutrition specific and nutrition sentitive interventions and building and enabling environment. Lancet, 2013 Nutrition-specific Interventions and Programs
Interventions or programs that address the immediate determinants of fetal and child nutrition and developmentdietary intake, feeding, caregiving and parenting practices, and infections Examples: Adolescent, preconception, and maternal health and nutrition Maternal dietary or micronutrient supplementation Promotion of optimum breastfeeding Complementary feeding and responsive feeding practices and stimulation Dietary supplementation Diversification and micronutrient supplementation or fortification for children Treatment of severe acute malnutrition Disease prevention and management Nutrition in emergencies Nutrition-sensitive Interventions and Programs
Interventions or programs that address the underlying determinants of fetal and child nutrition and development food security; adequate caregiving resources at maternal, household and community levels; and access to health services and a safe and hygienic environmentand incorporate specific nutrition goals and actions Nutrition-sensitive programs can serve as delivery platforms for nutrition-specific interventions, potentially increasing their scale, coverage and effectiveness Examples: Agriculture and food security Social safety nets Early child development Maternal mental health Womens empowerment Child protection Schooling Water, sanitation and hygiene Health and family planning services What Makes Programs Potentially Nutrition-sensitive?
They address critical underlying determinants of under nutrition They are implemented at large scale and are effective at reaching thepoorwho also have the highest malnutrition rates Accelerating progress in nutrition requires increasing the nutritional impact of effective, large-scale, nutrition-sensitive programmes Review of nutritional impact of Programs from 4 Sectors for evidence and gaps
Agriculture Social safety nets Early child development Schooling Selected based on: Relevance for nutrition Availability of evaluations of nutritional impact -Relevant in that they address the most of the important underlying causes of malnutrition -Of the four, agriculture and social safety meet the 4 criteria. -Early child hood development programs limited by coverage but included because child development and nutrition share many risk factors -schooling also important because of the evidence of parental education on nutrition and development High coverage of the poor Targeting: programs that are or could be targeted to reach nutritionally vulnerable groups Agricultural Programmes
Livelihoods and income Household food security Diet quality Womens income and empowerment Homestead food production Biofor-tification Livestock production and aquaculture Have impacts on several underlying determinants of nutrition:livelihood, hh food security, diet quality, womens income and empowerment and complement global efforts to stimulate agricultural productivity increasing producer incomes while protecting consumers from high food prices Nutritional Impacts of Targeted Agricultural Programmes
Although there is some evidence of impact from home gardens and homestead food production systems on vitamin A intake and status of children but this is limited What is the evidence of nutritional impact? Strong evidence from roll out of biofortified vitamin A rich orange sweet potato on vitamin A intake of mothers and children and vitamin A status of children Possible causes of limited evidence Weaknesses in program goals, design, targeting, implementation Social Safety Nets are very important poverty reduction tools:
Provide transfers to a billion poor people and reducepoverty; are often implemented at scale and achieve high coverage of the poor; increase demand for health and education services are very important poverty reduction tools: Help mitigate negative effects of global changes, conflicts, shocks Enhance womens empowerment when targeted to women and when they include specific gender-focused interventions Usually include food and cash transfers What is the evidence of nutritional impact? Strong evidence of impacts on health care utilisation, but limited impacts on child nutrition; some studies show impacts in younger, poorer children, with longer exposure Lack of clarity in nutrition goals, weaknesses in design and poor quality health services Possible cause of limited evidence Early Child Development
Stunting and poor cognitive development share many similar risk including: Nutritional deficiencies Intra-uterine growth restriction Social and economic conditions such as poverty and maternal depression Peak vulnerability: the first 1,000 days Evidence from small-scale programs targeted to at-risk children suggests additive effects on child development and in some cases on nutrition outcomes Interventions include core maternal and child nutrition interventions, physchosocial stumulation, responsive feeding etc. Also share a period of peak vulnerability.. What is the evidence of nutritional impact? Combining early child development and nutrition interventions makes sense biologically and programmatically and could lead to significant gains in both nutrition and child development outcomes Possible cause of limited evidence Weakness is on nutritional goals and outcomes. Need to be tested at scale. Schooling Risk of child stunting is significantly lower among mothers
Parental schooling is a critical input to nutrition Risk of child stunting is significantly lower among mothers with at least some primary schooling risk even lower for those with secondary schooling Schooling is important for the nutrition of the next generation Positive global trends in schooling reductions in gender gap What are the key findings Although school children are beyond the crucial 1000 days, their schooling experience may be a stonger determinant of nutrition for the next generation. More girls enrolled in primary and secondary schools Schools provide an opportunity to include specific nutritionpromotion and education to prevent or treat undernutrition in school children and future generations Assessments of the effectiveness of school programs on nutrition and on their future parenting skills of children are needed Possible cause of limited evidence Summary of major gaps Programmes in these sectors are successful
at addressing several underlying determinants of nutrition, but evidence of nutritional impact is still limited Enhancing the Nutrition-sensitivity of Programs
Improve targeting, timing and duration of exposure to interventions How can we make programs more nutrition sensitive? Use conditions to stimulate demand for program services Strengthen nutrition goals, design, implementation Optimise womens nutrition, time, physical and mental health and empowerment Own country experience
Which programs have been successful in your country to reduce maternal and child under nutrition What are the strengths and weaknesses of these programs?