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Global Food Programs to Eliminate Undernutrition

Rolf D. W. Klemm, MPH, DrPH Johns Hopkins University

 What do food and nutrition have to do with global disease control?

 Does size (place, timing, and other factors) really matter? Why? Why not?

 Are we making progress?

 Is there a framework for targeting effective action?

 What strategies work?

 What are the major policy and implementation challenges?

Outline

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Global Disease Control: Links With Food and Nutrition

Section A

High Food Prices Add Millions to the Hungry and Correspond With “Food Riots” and “Arab Spring”

Source: Lagi, M., Bertrand, K. Z., Bar-Yam, Y. (2011). The Food Crises and Political Instability in North Africa and the Middle East. arXiv:1108.2455. Available at: http://www.necsi.edu/research/social/foodcrises. html. Accessed February 13, 2015. 4

Food prices

Rising Food Prices Push People at the Margins Into Hunger

Source: Thomson Financial Datastream, FAO. 5

Financial Crisis Corresponded With Food Riots in the Streets

 Kenya slums, Time, 2008

Source: Time. (2008). 6

Not Surprisingly, “Food Security” Jumped to the Top of the G8 and G20 “To-Do” List

“We also announced a new alliance on food security with African leaders and the private sector as part of an effort to lift 50 million people out of poverty over the next decade.”

Source: Office of White House Press Secretary. (May 19, 2012). Statement by President Obama at Closing of G8 Summit [press release]. Available at: http://www.whitehouse.gov/the-press-office/2012/05/19/statement-president-obama-closing-g8-summit. Accessed January 26, 2015. 7

 Which of the following risk factors is responsible for causing the greatest burden of human death, disease, and disability each year? a. Unsafe sex (HIV-AIDs, etc.) b. Unsafe water, sanitation, or hygiene c. Alcohol use d. Child underweight e. High blood pressure

Food for Thought

WHO, Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risk Factors, 2009

Source: WHO. (2009). Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. World Health Organization. Available at: http://www.who.int/healthinfo/global_burden_ disease/global_health_risks. Accessed February 13, 2015. 9

WHO, Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risk Factors, 2009

11% of global DALYs

Undernutrition Causes 45% of Child Deaths, Resulting in 3.1 Million Deaths Annually

Adapted from: Black, R. E., Victora, C. G., Walker, S. P., et al. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet, 382(9890), 427–451. doi:10.1016/S0140-6736(13)60937-X 13

Nutritional disorders Attributable deaths

with UN prevalences*

Proportion of total deaths of children

younger than 5 years

Fetal growth restriction (<1 month)

Stunting (1-59 months)

Underweight (1-59 months)

Wasting (1-59 months)

Severe wasting (1-59 months)

Zinc deficiency (12-59 months)

Vitamin A deficiency (6-59 months)

Suboptimum breastfeeding (0-23 months)

Joint effects of fetal growth restriction and suboptimum breastfeeding in neonates

Joint effects of fetal growth restriction, suboptimum breastfeeding, stunting, wasting, and vitamin A and zinc deficiencies (<5 years)

Data are to the nearest thousand. *Prevalence estimates from the UN.

Undernutrition Causes 45% of Child Deaths, Resulting in 3.1 Million Deaths Annually

Nutritional disorders Attributable deaths

with UN prevalences*

Proportion of total deaths of children

younger than 5 years

Fetal growth restriction (<1 month) 817,000

Stunting (1-59 months) 1,017,000*

Underweight (1-59 months) 999,000*

Wasting (1-59 months) 875,000*

Severe wasting (1-59 months) 516,000*

Zinc deficiency (12-59 months) 116,000

Vitamin A deficiency (6-59 months) 157,000

Suboptimum breastfeeding (0-23 months) 804,000

Joint effects of fetal growth restriction and suboptimum breastfeeding in neonates

1,348,000

Joint effects of fetal growth restriction, suboptimum breastfeeding, stunting, wasting, and vitamin A and zinc deficiencies (<5 years)

3,097,000

Data are to the nearest thousand. *Prevalence estimates from the UN.

Undernutrition Causes 45% of Child Deaths, Resulting in 3.1 Million Deaths Annually

Nutritional disorders Attributable deaths

with UN prevalences*

Proportion of total deaths of children

younger than 5 years

Fetal growth restriction (<1 month) 817,000 11.8%

Stunting (1-59 months) 1,017,000* 14.7%

Underweight (1-59 months) 999,000* 14.4%

Wasting (1-59 months) 875,000* 12.6%

Severe wasting (1-59 months) 516,000* 7.4%

Zinc deficiency (12-59 months) 116,000 1.7%

Vitamin A deficiency (6-59 months) 157,000 2.3%

Suboptimum breastfeeding (0-23 months) 804,000 11.6%

Joint effects of fetal growth restriction and suboptimum breastfeeding in neonates

1,348,000 19.4%

Joint effects of fetal growth restriction, suboptimum breastfeeding, stunting, wasting, and vitamin A and zinc deficiencies (<5 years)

3,097,000 44.7%

Data are to the nearest thousand. *Prevalence estimates from the UN.

 What do food and nutrition have to do with global disease control?

 Does size (place, timing, and other factors) really matter? Why? Why not?

 Are we making progress?

 Is there a framework for targeting effective action?

 What strategies work?

 What are the major policy and implementation challenges?

Outline

Undernutrition

Protein energy malnutrition

Micronutrient malnutrition

Overnutrition

Obesity

Chronic excess of specific nutrients

Does Size Matter?

Undernutrition

Protein energy malnutrition Yes

Micronutrient malnutrition

Overnutrition

Obesity

Chronic excess of specific nutrients

Does Size Matter?

Undernutrition

Protein energy malnutrition Yes

Micronutrient malnutrition Not really

Overnutrition

Obesity

Chronic excess of specific nutrients

Does Size Matter?

Undernutrition

Protein energy malnutrition Yes

Micronutrient malnutrition Not really

Overnutrition

Obesity Yes

Chronic excess of specific nutrients

Does Size Matter?

Undernutrition

Protein energy malnutrition Yes

Micronutrient malnutrition Not really

Overnutrition

Obesity Yes

Chronic excess of specific nutrients Not really

Does Size Matter?

Wasting Versus Stunting

Image source: London School of Hygiene and Tropical Medicine. (2009). The use of epidemiological tools in conflict-affected populations: open-access educational resources for policy-makers. Available at: http://conflict.lshtm.ac.uk/page_115.htm. Accessed February 13, 2015. 22

Wasting

• Low weight for a given stature • Current nutritional status • Reflects presence of stress episode at

time of measurement (e.g., illness, deprivation due to seasonal shortages, sudden catastrophe)

Wasting Versus Stunting

Wasting

• Low weight for a given stature • Current nutritional status • Reflects presence of stress episode at

time of measurement (e.g., illness, deprivation due to seasonal shortages, sudden catastrophe)

Stunting

• Retardation in linear growth • Long-term undernutrition • Usually indicates cumulative history

of stress episodes (e.g., chronic food insecurity, poor feeding practices, protracted health problems)

Wasting Versus Stunting

Wasting

• Low weight for a given stature • Current nutritional status • Reflects presence of stress episode at

time of measurement (e.g., illness, deprivation due to seasonal shortages, sudden catastrophe)

Stunting

• Retardation in linear growth • Long-term undernutrition • Usually indicates cumulative history

of stress episodes (e.g., chronic food insecurity, poor feeding practices, protracted health problems)

Wasting Is Accompanied by High Mortality

Source: Black, R. E., et al. (2013). Lancet. 25

Wasting Is Accompanied by High Mortality

~20% of all child deaths attributed to acute

malnutrition

Source: Black, R. E., et al. (2013). Lancet. 26

Hazard ratio (95% confidence interval)

Weight- for-

length Z-score

All deaths

Pneumonia deaths

Diarrhea deaths

Measles deaths

Other infectious

deaths

< -3 11.6 (9.8, 13.8) 9.7 (6.1, 15.4) 12.3 (9.2, 16.6) 9.6 (5.1, 18.0) 11.2 (5.9, 21.3)

-3 to < -2 3.4 (2.9, 4.0) 4.7 (3.1, 7.1) 3.4 (2.5, 4.6) 2.6 (1.3, 5.1) 2.7 (1.4, 5.5)

-2 to < -1 1.6 (1.4, 1.9) 1.9 (1.3, 2.8) 1.6 (1.2, 2.1) 1.0 (0.6, 1.9) 1.7 (1.0, 2.8)

≥ -1 1.0 1.0 1.0 1.0 1.0

When Coupled With Infectious Diseases, Wasting Increases Hazard of Death

Source: Black, R. E., et al. (2013). Lancet. 27

Hazard ratio (95% confidence interval)

Weight- for-

length Z-score

All deaths

Pneumonia deaths

Diarrhea deaths

Measles deaths

Other infectious

deaths

< -3 11.6 (9.8, 13.8) 9.7 (6.1, 15.4) 12.3 (9.2, 16.6) 9.6 (5.1, 18.0) 11.2 (5.9, 21.3)

-3 to < -2 3.4 (2.9, 4.0) 4.7 (3.1, 7.1) 3.4 (2.5, 4.6) 2.6 (1.3, 5.1) 2.7 (1.4, 5.5)

-2 to < -1 1.6 (1.4, 1.9) 1.9 (1.3, 2.8) 1.6 (1.2, 2.1) 1.0 (0.6, 1.9) 1.7 (1.0, 2.8)

≥ -1 1.0 1.0 1.0 1.0 1.0

When Coupled With Infectious Diseases, Wasting Increases Hazard of Death

Source: Black, R. E., et al. (2013). Lancet. 28

M or

e s

e ve

re w

as ti

n g

Hazard ratio (95% confidence interval)

Weight- for-

length Z-score

All deaths

Pneumonia deaths

Diarrhea deaths

Measles deaths

Other infectious

deaths

< -3 11.6 (9.8, 13.8) 9.7 (6.1, 15.4) 12.3 (9.2, 16.6) 9.6 (5.1, 18.0) 11.2 (5.9, 21.3)

-3 to < -2 3.4 (2.9, 4.0) 4.7 (3.1, 7.1) 3.4 (2.5, 4.6) 2.6 (1.3, 5.1) 2.7 (1.4, 5.5)

-2 to < -1 1.6 (1.4, 1.9) 1.9 (1.3, 2.8) 1.6 (1.2, 2.1) 1.0 (0.6, 1.9) 1.7 (1.0, 2.8)

≥ -1 1.0 1.0 1.0 1.0 1.0

When Coupled With Infectious Diseases, Wasting Increases Hazard of Death

Source: Black, R. E., et al. (2013). Lancet. 29

M or

e s

e ve

re w

as ti

n g

H ig

h e r

ri sk

o f

d e at

Hazard ratio (95% confidence interval)

Height/ length- for-age Z-score

All deaths

Pneumonia deaths

Diarrhea deaths

Measles deaths

Other infectious

deaths

< -3 5.5 (4.6, 6.5) 6.4 (4.2, 9.8) 6.3 (4.6, 8.7) 6.0 (3.0, 12.0) 3.0 (1.6, 5.8)

-3 to < -2 2.3 (1.9, 2.7) 2.2 (1.4, 3.4) 2.4 (1.7, 3.3) 2.8 (1.4, 5.6) 1.9 (1.0, 3.6)

-2 to < -1 1.5 (1.2, 1.7) 1.6 (1.0, 2.4) 1.7 (1.2, 2.3) 1.3 (0.6, 2.6) 0.9 (0.5, 1.9)

≥ -1 1.0 1.0 1.0 1.0 1.0

A Lethal Combination: Stunting Increases Hazard of Death in Children

Source: Black, R. E., et al. (2013). Lancet. 30

Hazard ratio (95% confidence interval)

Height/ length- for-age Z-score

All deaths

Pneumonia deaths

Diarrhea deaths

Measles deaths

Other infectious

deaths

< -3 5.5 (4.6, 6.5) 6.4 (4.2, 9.8) 6.3 (4.6, 8.7) 6.0 (3.0, 12.0) 3.0 (1.6, 5.8)

-3 to < -2 2.3 (1.9, 2.7) 2.2 (1.4, 3.4) 2.4 (1.7, 3.3) 2.8 (1.4, 5.6) 1.9 (1.0, 3.6)

-2 to < -1 1.5 (1.2, 1.7) 1.6 (1.0, 2.4) 1.7 (1.2, 2.3) 1.3 (0.6, 2.6) 0.9 (0.5, 1.9)

≥ -1 1.0 1.0 1.0 1.0 1.0

A Lethal Combination: Stunting Increases Hazard of Death in Children

Source: Black, R. E., et al. (2013). Lancet. 31

M or

e s

e ve

re s

tu n ti

n g

Hazard ratio (95% confidence interval)

Height/ length- for-age Z-score

All deaths

Pneumonia deaths

Diarrhea deaths

Measles deaths

Other infectious

deaths

< -3 5.5 (4.6, 6.5) 6.4 (4.2, 9.8) 6.3 (4.6, 8.7) 6.0 (3.0, 12.0) 3.0 (1.6, 5.8)

-3 to < -2 2.3 (1.9, 2.7) 2.2 (1.4, 3.4) 2.4 (1.7, 3.3) 2.8 (1.4, 5.6) 1.9 (1.0, 3.6)

-2 to < -1 1.5 (1.2, 1.7) 1.6 (1.0, 2.4) 1.7 (1.2, 2.3) 1.3 (0.6, 2.6) 0.9 (0.5, 1.9)

≥ -1 1.0 1.0 1.0 1.0 1.0

A Lethal Combination: Stunting Increases Hazard of Death in Children

Source: Black, R. E., et al. (2013). Lancet. 32

M or

e s

e ve

re s

tu n ti

n g

H ig

h e r

ri sk

o f

d e at

The “Vicious Cycle” of Undernutrition and Infection

Does Place Matter?

Data source: UNICEF. 34

% Children 0-59 months of age who are underweight (by NCHS/WHO reference population), by residence

Region Rural Urban Ratio

Latin American and Caribbean 12 5 2.3

East Asia and Pacific 13 7 1.9

CEE/CIS 6 3 1.8

Middle East and North Africa 18 10 1.8

Sub-Saharan Africa 30 18 1.6

South Asia 49 38 1.3

Developing countries 29 15 2.0

Does Place Matter?

Data source: UNICEF. 35

% Children 0-59 months of age who are underweight (by NCHS/WHO reference population), by residence

Region Rural Urban Ratio

Latin American and Caribbean 12 5 2.3

East Asia and Pacific 13 7 1.9

CEE/CIS 6 3 1.8

Middle East and North Africa 18 10 1.8

Sub-Saharan Africa 30 18 1.6

South Asia 49 38 1.3

Developing countries 29 15 2.0

Rural children twice as likely to be

underweight as urban children

Does Timing Matter?

36 Adapted from: Shrimpton, R., Victora, C. G., de Onis, M., Lima, R. C., Blössner, M., & Clugston, G. (2001). Worldwide timing of growth faltering: implications for nutritional interventions. Pediatrics, 107(5), E75.

Does Timing Matter?

37 Adapted from: Shrimpton, R., Victora, C. G., de Onis, M., Lima, R. C., Blössner, M., & Clugston, G. (2001). Worldwide timing of growth faltering: implications for nutritional interventions. Pediatrics, 107(5), E75.

Does Timing Matter?

38 Adapted from: Shrimpton, R., et al. (2001). Pediatrics, 107(5), E75.

A limited “window of opportunity” to prevent undernutrition?

First 1,000 Days, or Last 730 Days?

270 730

Adolescence

Pregnancy

1,000 days

First 1,000 Days, or Last 730 Days?

Conception Birth 2 years

270 730

Adolescence

Pregnancy

1,000 days

Does Size at Birth Matter? Small-for-Gestational Age (SGA)

Source: Black, R. E., Victora, C. G., Walker, S. P., et al. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet, 382(9890), 427–451. doi:10.1016/S0140-6736(13)60937-X 41

Does Size at Birth Matter? Small-for-Gestational Age (SGA)

 Three-fold higher risk of neonatal death

 Two-fold higher risk of post- neonatal death

 11.8% of death <5 years

 4.5 times higher risk of stunting

 Responsible for ~20% of childhood stunting

What Else Matters?

Data source: UNICEF. 43

% Children 0-59 months of age who are underweight (by NCHS/WHO reference population), by household wealth level

Region Poorest Richest Ratio

Latin American and Caribbean 15 3 4.5

CEE/CIS 7 3 2.6

East Asia and Pacific 28 12 2.3

South Asia 56 25 2.3

Sub-Saharan Africa 32 15 2.1

Middle East and North Africa 11 5 2.1

Developing countries 26 11 2.3

What Else Matters?

Data source: UNICEF. 44

% Children 0-59 months of age who are underweight (by NCHS/WHO reference population), by household wealth level

Region Poorest Richest Ratio

Latin American and Caribbean 15 3 4.5

CEE/CIS 7 3 2.6

East Asia and Pacific 28 12 2.3

South Asia 56 25 2.3

Sub-Saharan Africa 32 15 2.1

Middle East and North Africa 11 5 2.1

Developing countries 26 11 2.3

Poor children more than twice as likely to be underweight as rich

children

Does Maternal Size Matter?

Source: UNICEF, SOWC, 2009; McClean. (2008). Public Health Nutr. Christian, P. (2006). Access presentation.

South Asia

Sub-Saharan Africa

Developed countries

Low weight (<45 kg or 99 lb) 63 ↑ 4× 23 ↑ 10× 5-6 Short height (<145 cm or 4’7”) 21 ↑ 2× 6 ↑ 6× 3-4 Low body mass index (<18.5) 34 ↑ 4.5× 18 ↑ 9× 4

Does Maternal Size Matter?

Source: UNICEF, SOWC, 2009; McClean. (2008). Public Health Nutr. Christian, P. (2006). Access presentation.

South Asia

Sub-Saharan Africa

Developed countries

Low weight (<45 kg or 99 lb) 63 ↑ 4× 23 ↑ 10× 5-6 Short height (<145 cm or 4’7”) 21 ↑ 2× 6 ↑ 6× 3-4 Low body mass index (<18.5) 34 ↑ 4.5× 18 ↑ 9× 4 Low birth weight 27 ↑ 2× 15 ↑ 4× 7 Infant mortality rate 59 ↑ 5× 89 ↑ 3.5× 5 Maternal mortality rate 500 920 8

Protein Energy Malnutrition (PEM) Starts In Utero

 Both pups six weeks old:  One born to well-

nourished mother  One born to

undernourished mother

Does Age at First Pregnancy Matter?

The sooner after menarche girls got pregnant, the worse their nutritional status 48

Does Micronutrient Status Matter?

Vitamin A deficiency (serum retinol <0.70 μmol/L)

Iron deficiency anemia (hemoglobin <110 g/L)

Children <5 years

Iodine deficiency

(UIC <100 μg/L)

Zinc deficiency (weighted average of country means)

Children <5 years

Pregnant women

Global 33.3% 28.5% 17.3% 18.1% 19.2%

Africa 41.6% 40.0% 23.9% 20.2% 20.3%

Americas and the Caribbean

15.6% 13.7% 9.6% 12.7% 15.2%

Asia 33.5% 31.6% 19.4% 19.0% 19.8%

Europe 14.9% 44.2% 7.6% 12.1% 16.2%

Data are % (95% CI). UIC=urine iodine concentration.

Nutrition Strategies That Work

Section B

 What do food and nutrition have to do with global disease control?

 Does size (place, timing, and other factors) really matter? Why? Why not?

 Are we making progress?

 Is there a framework for targeting effective action?

 What strategies work?

 What are the major policy and implementation challenges?

Outline

All Regions Have Made Progress in Reducing Childhood Underweight, but Decline Is Slow, Especially in South Asia and Africa

Source: UNICEF. http://www.childinfo.org/undernutrition_progress.html 3

From left to right in each region:

All Regions Have Made Progress in Reducing Childhood Underweight, but Decline Is Slow, Especially in South Asia and Africa

Source: UNICEF. http://www.childinfo.org/undernutrition_progress.html

0.2%-0.3% decline per year

From left to right in each region:

All Regions Have Reduced Stunting Prevalence Since 1991

Source: UNICEF. (2013). Improving Child Nutrition: The Achievable Imperative for Global Progress. Available at: http://www.unicef.org/publications/index_68661. html. Accessed February 15, 2015. 5

Percentage of children under age 5 who are moderately or severely stunted and percentage reduction, 1990–2011

↓1.7%/year

↓3.4%/year

↓1.1%/year

↓0.5%/year

All Regions Have Reduced Stunting Prevalence Since 1991

Source: UNICEF. (2013). Improving Child Nutrition: The Achievable Imperative for Global Progress. Available at: http://www.unicef.org/publications/index_68661. html. Accessed February 15, 2015. 6

Percentage of children under age 5 who are moderately or severely stunted and percentage reduction, 1990–2011

↓1.7%/year

↓3.4%/year

↓1.1%/year

↓0.5%/year

But 165 million children <5 years of age are still stunted, and undernutrition is still responsible for 45% of all deaths

among children <5 years old

Eighty Percent of the World’s Stunted Children Live in 14 Countries

Source: UNICEF. (2013). Improving Child Nutrition: The Achievable Imperative for Global Progress. Available at: http://www.unicef.org/publications/index_68661.html. Accessed February 15, 2015. 7

 What do food and nutrition have to do with global disease control?

 Does size (place, timing, and other factors) really matter? Why? Why not?

 Are we making progress?

 Is there a framework for targeting effective action?

 What strategies work?

 What are the major policy and implementation challenges?

Outline

Framework

Immediate

Underlying

Basic

Framework

Immediate

Underlying

Basic

Direct nutrition interventions

Framework

Immediate

Underlying

Basic

Direct nutrition interventions

“Nutrition- sensitive” interventions

Framework

Immediate

Underlying

Basic

Direct nutrition interventions

“Nutrition- sensitive” interventions Agriculture and food security Social safety nets Water, sanitation, and hygiene Women’s empowerment Schooling Governance

Supplementation Fortification Dietary intake Breast feeding

Framework  Multifaceted

 Complex

 Multileveled

 No single cause

 What do food and nutrition have to do with global disease control?

 Does size (place, timing, and other factors) really matter? Why? Why not?

 Are we making progress?

 Is there a framework for targeting effective action?

 What strategies work?

 What are the major policy and implementation challenges?

Outline

Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost? (Bhutta, et al., 2013)

Source: Bhutta, Z. A., Das, J. K., Rizvi, A., et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet, 382(9890), 452–477. doi:10.1016/S0140-6736(13)60996-4 16

Interventions Across the Lifecycle

46% Reduction in Neural-Tube Defects After Folic Acid Fortification in Canada

Source: De Wals, P., Tairou, F., Van Allen, M. I., et al. (2007). Reduction in neural-tube defects after folic acid fortification in Canada. The New England Journal of Medicine, 357(2), 135–142. doi:10.1056/NEJMoa067103 20

46% Reduction in Neural-Tube Defects After Folic Acid Fortification in Canada

Mandatory fortification of cereals with folic acid

Multiple Micronutrient Supplementation Versus Iron-Folic Acid in Pregnancy (Haider and Bhutta, 2012)

Relative to IFA, MMS … RR (95% CI)

↓ LBW by 11% 0.89 (0.83, 0.94)

↓ SGA by 13% 0.87 (0.81, 0.95) No significant difference in PTB, SB, NMR. N=21 trials; N=75,785 women MMS indicates multiple micronutrient supplements; IFA, iron-folic acid; LBW, low birth weight; SGA, small for gestational age; PTB, pre-term birth; SB, still birth; and NMR, neonatal mortality rate.

Source: Haider, B. A., & Bhutta, Z. A. (2012). Multiple-micronutrient supplementation for women during pregnancy. The Cochrane Database of Systematic Reviews, 11, CD004905. doi:10.1002/14651858.CD004905.pub3 22

Multiple Micronutrient Supplementation Versus Iron-Folic Acid in Pregnancy (Haider and Bhutta, 2012)

Relative to IFA, MMS … RR (95% CI)

↓ LBW by 11% 0.89 (0.83, 0.94)

 Is it time to move to multiple micronutrient supplements?

Interventions Across the Lifecycle

Neonatal Vitamin A

Source: Imdad, A., Yakoob, M. Y., Sudfeld, C., Haider, B. A., Black, R. E., & Bhutta, Z. A. (2011). Impact of vitamin A supplementation on infant and childhood mortality. BMC Public Health, 11 Suppl 3, S20. doi:10.1186/1471-2458-11-S3-S20

Asian studies: 17% reduction

African studies: no reduction

Overall: 12% reduction

Interventions Across the Lifecycle

Vitamin A Supplementation Can Reduce Child Mortality by ~30%, Saving 1 to 2.5 Million Lives per Year

Source: Sommer and West. (1996). 27

Micronutrient Powders: Iron, Vitamin A, Zinc, Folic Acid, and Vitamin C

Many Products … but Guidance and Consensus Not Consistent on Nutrient Composition, Objective, Use, or Safety

Should Ready-to-Use Foods Be Used to Prevent Child Undernutrition?

30 Source: Enserink, M. (2008). Nutrition science. The peanut butter debate. Science (New York, N.Y.), 322(5898), 36–38. doi:10.1126/science.322.5898.36

Policy and Implementation Challenges

Section C

 What do food and nutrition have to do with global disease control?

 Does size (place, timing, and other factors) really matter? Why? Why not?

 Are we making progress?

 Is there a framework for targeting effective action?

 What strategies work?

 What are the major policy and implementation challenges?

Outline

Today’s Solutions—but Only If They Reach and Are Used by Risk Groups, Where and When Needed, With Adequate Quality

Closing the “Know–Do” Gap

Gap Know Do

 Strengthen capacity to use “implementation science” methods to generate evidence on how to take efficacious interventions to scale

Closing the “Know–Do” Gap

Gap Know Do

“Thank God! A Panel of Experts!”

 Magnitude and severity of problem

 Efficacy

 Cost-effectiveness

 Sustainability

 Safety

 Delivery platform (primary health care, community-based, social marketing, commercial channels, combinations?)

 Longer-term impacts on health and nutrition

 Possible adverse effects (e.g., on breastfeeding practices, later obesity, chronic disease)

 Commercial interests

 Local production potential—benefits, risks

Scale-Up of Nutrition Products to Prevent Malnutrition Depends on …

 Fragmented and competing policy communities

 Absence of leadership

 Multiple “guiding institutions” providing fragmented guidance

 Fragmented targets (prepregnancy, pregnancy, infancy, childhood)

 Complex factors

 Serious consequences not well understood

 Solutions not quick or easy

 Affects poor (uneducated) rural population who tend not to be “politically vocal”

Why Has Global Action Been So Difficult?

Coordinated Global Guidance: True Coordination or “Logo Soup”?

Source: Scaling Up Nutrition: A Framework for Action. Available at: http://scalingupnutrition.org/resources-archive. Accessed February 16, 2015. 10

1,000 Days: Change a Life, Change the Future

9 months 0-24 months + = 36 months

~1,000 days

Windows of Opportunity

 Kenya slums, Time, 2008

Source: Time. (2008). 12

 Undernutrition is one of the world’s most serious but least addressed health problems

 It involves enormous morbidity, mortality, development, and economic costs

 Burden falls mostly on women and children

 Undernutrition is largely preventable

 Consensus exists on 10 evidence-based interventions—scale-up is needed, but how?

 More evidence is needed on “nutrition-sensitive” interventions

Conclusions

Lecture Evaluation

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