Strategies for Addressing Strategies for Addressing Chronic Malnutrition in Chronic Malnutrition in

Infants and Young ChildrenInfants and Young Children

Strategies for Addressing Strategies for Addressing Chronic Malnutrition in Chronic Malnutrition in

Infants and Young ChildrenInfants and Young Children

Mary Arimond, IFPRIMary Arimond, IFPRI

andand

Judy Canahuati, USAIDJudy Canahuati, USAID

Mary Arimond, IFPRIMary Arimond, IFPRI

andand

Judy Canahuati, USAIDJudy Canahuati, USAID

IFAC, Tuesday, April 15IFAC, Tuesday, April 15Photo: CARE USAPhoto: CARE USA

OutlineOutlineOutlineOutline

• Window of opportunity: Window of opportunity: conception- 24 monthsconception- 24 months

• Why does growth falter?Why does growth falter?• Prevention vs. curePrevention vs. cure• Guiding Principles for feedingGuiding Principles for feeding• ““Problem” nutrients; nutrient gapsProblem” nutrients; nutrient gaps• Options for filling the gapsOptions for filling the gaps• Indicators for measuring progressIndicators for measuring progress

• Window of opportunity: Window of opportunity: conception- 24 monthsconception- 24 months

• Why does growth falter?Why does growth falter?• Prevention vs. curePrevention vs. cure• Guiding Principles for feedingGuiding Principles for feeding• ““Problem” nutrients; nutrient gapsProblem” nutrients; nutrient gaps• Options for filling the gapsOptions for filling the gaps• Indicators for measuring progressIndicators for measuring progress

Chronic malnutrition begins Chronic malnutrition begins early*early*

Chronic malnutrition begins Chronic malnutrition begins early*early*

*Lancet series on Nutrition 2008 *Lancet series on Nutrition 2008 www.GlobalNutritionSeries.org,

WB WB Repositioning Nutrition as Central to DevelopmentRepositioning Nutrition as Central to Development, 2006, 2006http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdfNutritionStrategy.pdf

*Lancet series on Nutrition 2008 *Lancet series on Nutrition 2008 www.GlobalNutritionSeries.org,

WB WB Repositioning Nutrition as Central to DevelopmentRepositioning Nutrition as Central to Development, 2006, 2006http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdfNutritionStrategy.pdf

Period of most rapid growth and Period of most rapid growth and vulnerability to growth falteringvulnerability to growth faltering

Period of most rapid growth and Period of most rapid growth and vulnerability to growth falteringvulnerability to growth faltering

-2

-1.75

-1.5

-1.25

-1

-0.75

-0.5

-0.25

0

0.25

0.5

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

We

igh

t fo

r a

ge

Z-s

co

re (

NC

HS

)

Africa Latin America and Caribbean Asia

Shrimpton et al. 2001Shrimpton et al. 2001

•Age (months)Age (months)•Age (months)Age (months)

Greatest benefits from nutrition Greatest benefits from nutrition interventionsinterventions

in first 2-3 years (Guatemala)in first 2-3 years (Guatemala)

Greatest benefits from nutrition Greatest benefits from nutrition interventionsinterventions

in first 2-3 years (Guatemala)in first 2-3 years (Guatemala)

-10123456789

10

3-12

12-24

24-36

36-48

48-60

60-72

72-84

-10123456789

10

3-12

12-24

24-36

36-48

48-60

60-72

72-84

An

nu

al le

ng

th g

ain

(m

m)

0-36 mo 36-84 mo

Schroeder, D., Martorell, R., Rivera, J., Ruel, M.T. and Habicht, J.P. Schroeder, D., Martorell, R., Rivera, J., Ruel, M.T. and Habicht, J.P. Age differences in the impact of supplementation on growthAge differences in the impact of supplementation on growth J. NutrJ. Nutr. 125 (suppl):1060S-1067S, 1995. 125 (suppl):1060S-1067S, 1995

Annual Annual changechange in length by age, with consumption of an in length by age, with consumption of an additional 100 kcal/d of high-energy/protein supplementadditional 100 kcal/d of high-energy/protein supplement

Age

Prevention can be Prevention can be more effective than “cure”more effective than “cure”

Prevention can be Prevention can be more effective than “cure”more effective than “cure”

0

5

10

15

20

25

30

35

40

Stunting Underweight Wasting

%

Baseline combined Recuperative final Preventive final

P=0.10P=0.10

P<0.05P<0.05

P<0.05P<0.05

Random effects logit models (adj. for cluster effects and controlling for age, sex)Random effects logit models (adj. for cluster effects and controlling for age, sex)

4pp4pp

6pp6pp

4pp4pp

Ruel et al., 2008Ruel et al., 2008

Guiding Principles for Feeding Guiding Principles for Feeding Infants and Young Children Infants and Young Children

Guiding Principles for Feeding Guiding Principles for Feeding Infants and Young Children Infants and Young Children

• Provide a framework for Provide a framework for understanding, assessing, and understanding, assessing, and improving infant and young child improving infant and young child feedingfeeding

• Developed first for breastfed Developed first for breastfed children (PAHO/WHO, 2001) and children (PAHO/WHO, 2001) and then for non-breastfed (WHO, 2005)then for non-breastfed (WHO, 2005)

• Cover age range of 0-24 Cover age range of 0-24 months months

• Provide a framework for Provide a framework for understanding, assessing, and understanding, assessing, and improving infant and young child improving infant and young child feedingfeeding

• Developed first for breastfed Developed first for breastfed children (PAHO/WHO, 2001) and children (PAHO/WHO, 2001) and then for non-breastfed (WHO, 2005)then for non-breastfed (WHO, 2005)

• Cover age range of 0-24 Cover age range of 0-24 months months

Multiple dimensions of infant and Multiple dimensions of infant and young child feedingyoung child feeding

Multiple dimensions of infant and Multiple dimensions of infant and young child feedingyoung child feeding

If breastfedIf breastfed::

• Breastfeed exclusively to 6 months, then introduce Breastfeed exclusively to 6 months, then introduce complementary foodscomplementary foods

• Continue on-demand breastfeeding until 24 months or Continue on-demand breastfeeding until 24 months or beyondbeyond

If not breastfedIf not breastfed::

• Meet child’s fluid needs with safe fluids, including clean Meet child’s fluid needs with safe fluids, including clean waterwater

BothBoth::

• Practice responsive feedingPractice responsive feeding

• Practice good hygiene and food handlingPractice good hygiene and food handling

• Ensure that energy needs are metEnsure that energy needs are met

If breastfedIf breastfed::

• Breastfeed exclusively to 6 months, then introduce Breastfeed exclusively to 6 months, then introduce complementary foodscomplementary foods

• Continue on-demand breastfeeding until 24 months or Continue on-demand breastfeeding until 24 months or beyondbeyond

If not breastfedIf not breastfed::

• Meet child’s fluid needs with safe fluids, including clean Meet child’s fluid needs with safe fluids, including clean waterwater

BothBoth::

• Practice responsive feedingPractice responsive feeding

• Practice good hygiene and food handlingPractice good hygiene and food handling

• Ensure that energy needs are metEnsure that energy needs are met

Continued…….

Multiple dimensions of infant and Multiple dimensions of infant and young child feeding, cont.young child feeding, cont.

Multiple dimensions of infant and Multiple dimensions of infant and young child feeding, cont.young child feeding, cont.

Both breastfed & non-breastfedBoth breastfed & non-breastfed::

• Gradually increase consistency and variety as Gradually increase consistency and variety as infant developsinfant develops

• Feeding frequency: 2-3 times plus snacks (BF), Feeding frequency: 2-3 times plus snacks (BF), 4-5 times (non-BF) plus snacks4-5 times (non-BF) plus snacks

• Sufficient energy density of foods (e.g. “thick” Sufficient energy density of foods (e.g. “thick” vs.watery gruels)vs.watery gruels)

• Feed a variety of foods to ensure all nutrient Feed a variety of foods to ensure all nutrient needs are metneeds are met

• Feed specially fortified foods and/or give Feed specially fortified foods and/or give supplements to fill gapssupplements to fill gaps

• Feed appropriately during and after illnessFeed appropriately during and after illness

Both breastfed & non-breastfedBoth breastfed & non-breastfed::

• Gradually increase consistency and variety as Gradually increase consistency and variety as infant developsinfant develops

• Feeding frequency: 2-3 times plus snacks (BF), Feeding frequency: 2-3 times plus snacks (BF), 4-5 times (non-BF) plus snacks4-5 times (non-BF) plus snacks

• Sufficient energy density of foods (e.g. “thick” Sufficient energy density of foods (e.g. “thick” vs.watery gruels)vs.watery gruels)

• Feed a variety of foods to ensure all nutrient Feed a variety of foods to ensure all nutrient needs are metneeds are met

• Feed specially fortified foods and/or give Feed specially fortified foods and/or give supplements to fill gapssupplements to fill gaps

• Feed appropriately during and after illnessFeed appropriately during and after illness

““Problem” nutrients for Problem” nutrients for infants & young children*infants & young children*““Problem” nutrients for Problem” nutrients for infants & young children*infants & young children*

Vitamin AVitamin A CalciumCalcium

ThiaminThiamin IronIron

RiboflavinRiboflavin ZincZinc

Vitamin B6Vitamin B6

FolateFolate

Non-BFNon-BF: B12** : B12** **

Vitamin CVitamin C

Vitamin AVitamin A CalciumCalcium

ThiaminThiamin IronIron

RiboflavinRiboflavin ZincZinc

Vitamin B6Vitamin B6

FolateFolate

Non-BFNon-BF: B12** : B12** **

Vitamin CVitamin C

****Dewey, 2005, GP Non-BF, pp.15, 20Dewey, 2005, GP Non-BF, pp.15, 20

Nutrient gaps for 6-24 moNutrient gaps for 6-24 moNutrient gaps for 6-24 moNutrient gaps for 6-24 mo

• 10-site (9-country) study identified gaps in 10-site (9-country) study identified gaps in nutrient intakes for non-BF and in nutrient nutrient intakes for non-BF and in nutrient density of complementary food for BFdensity of complementary food for BF

• Multiple micronutrient gaps in all sitesMultiple micronutrient gaps in all sites• Gaps were greatest for youngest (6-8 mo)Gaps were greatest for youngest (6-8 mo)• Some nutrients (e.g. vitamin A) were Some nutrients (e.g. vitamin A) were

problematic in some sites but not othersproblematic in some sites but not others• Some were problematic in most or all sites Some were problematic in most or all sites

(e.g. iron; size of gap between desired and (e.g. iron; size of gap between desired and actual also greatest for iron)actual also greatest for iron)

• 10-site (9-country) study identified gaps in 10-site (9-country) study identified gaps in nutrient intakes for non-BF and in nutrient nutrient intakes for non-BF and in nutrient density of complementary food for BFdensity of complementary food for BF

• Multiple micronutrient gaps in all sitesMultiple micronutrient gaps in all sites• Gaps were greatest for youngest (6-8 mo)Gaps were greatest for youngest (6-8 mo)• Some nutrients (e.g. vitamin A) were Some nutrients (e.g. vitamin A) were

problematic in some sites but not othersproblematic in some sites but not others• Some were problematic in most or all sites Some were problematic in most or all sites

(e.g. iron; size of gap between desired and (e.g. iron; size of gap between desired and actual also greatest for iron)actual also greatest for iron)

Working group on Infant and Young Child Feeding Indicators, 2006Working group on Infant and Young Child Feeding Indicators, 2006

Filling the gapFilling the gapFilling the gapFilling the gap

• Fortified commodities have a role to Fortified commodities have a role to playplay

• As currently formulated, don’t fill the As currently formulated, don’t fill the gaps for iron and zinc in infancy (6-12 gaps for iron and zinc in infancy (6-12 mo)mo)11

• Micronutrient fortified “sprinkles” and Micronutrient fortified “sprinkles” and spreads have shown promise in filling spreads have shown promise in filling some micronutrient gapssome micronutrient gaps

• New efforts underway to define New efforts underway to define standards for micronutrient content of standards for micronutrient content of both foods specially fortified for IYC and both foods specially fortified for IYC and for micronutrient powdersfor micronutrient powders22

• Fortified commodities have a role to Fortified commodities have a role to playplay

• As currently formulated, don’t fill the As currently formulated, don’t fill the gaps for iron and zinc in infancy (6-12 gaps for iron and zinc in infancy (6-12 mo)mo)11

• Micronutrient fortified “sprinkles” and Micronutrient fortified “sprinkles” and spreads have shown promise in filling spreads have shown promise in filling some micronutrient gapssome micronutrient gaps

• New efforts underway to define New efforts underway to define standards for micronutrient content of standards for micronutrient content of both foods specially fortified for IYC and both foods specially fortified for IYC and for micronutrient powdersfor micronutrient powders221 1 Ruel et al, 2004Ruel et al, 2004

•22 GAIN. GAIN. Proposed products and formulations for Proposed products and formulations for GAIN’s IYCN Program supportGAIN’s IYCN Program support, draft, February, 2007, draft, February, 2007

How can we measure How can we measure progress?progress?

How can we measure How can we measure progress?progress?

• Using framework of Guiding Using framework of Guiding Principles…Principles…

• Multi-year collaborative project Multi-year collaborative project to develop indicators for quality to develop indicators for quality of infant and young child feedingof infant and young child feeding

• New indicators to be published New indicators to be published by WHO and partners (IFPRI, UC by WHO and partners (IFPRI, UC Davis, FANTA Project) in 2008Davis, FANTA Project) in 2008**

• Using framework of Guiding Using framework of Guiding Principles…Principles…

• Multi-year collaborative project Multi-year collaborative project to develop indicators for quality to develop indicators for quality of infant and young child feedingof infant and young child feeding

• New indicators to be published New indicators to be published by WHO and partners (IFPRI, UC by WHO and partners (IFPRI, UC Davis, FANTA Project) in 2008Davis, FANTA Project) in 2008**

**http://www.who.int/child_adolescent_health/documents/pdfs/http://www.who.int/child_adolescent_health/documents/pdfs/iycf_indicators_for_peer_review.pdfiycf_indicators_for_peer_review.pdf

To sum up…To sum up…To sum up…To sum up…

• Chronic malnutrition develops very Chronic malnutrition develops very early, in some places, even before birth.early, in some places, even before birth.

• Pregnancy and the period up to 2 years Pregnancy and the period up to 2 years of age is a critical period for addressing of age is a critical period for addressing chronic malnutrition.chronic malnutrition.

• A combination of programmatic A combination of programmatic strategies supporting adequate strategies supporting adequate nutrition and care and a reconsideration nutrition and care and a reconsideration of nutrient delivery for mothers and of nutrient delivery for mothers and infants are showing promise in infants are showing promise in addressing chronic malnutrition, the addressing chronic malnutrition, the most widespread type of malnutrition in most widespread type of malnutrition in the developing world.the developing world.

• Chronic malnutrition develops very Chronic malnutrition develops very early, in some places, even before birth.early, in some places, even before birth.

• Pregnancy and the period up to 2 years Pregnancy and the period up to 2 years of age is a critical period for addressing of age is a critical period for addressing chronic malnutrition.chronic malnutrition.

• A combination of programmatic A combination of programmatic strategies supporting adequate strategies supporting adequate nutrition and care and a reconsideration nutrition and care and a reconsideration of nutrient delivery for mothers and of nutrient delivery for mothers and infants are showing promise in infants are showing promise in addressing chronic malnutrition, the addressing chronic malnutrition, the most widespread type of malnutrition in most widespread type of malnutrition in the developing world.the developing world.