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How is DOHaD affecting policy? Dr. Chessa Lutter Principal Advisor Santiago de Chile, November 19-22, 2009

. . How is DOHaD affecting policy? Dr. Chessa Lutter Principal Advisor Santiago de Chile, November 19-22, 2009 What does it take for DOHaD to influence policy? Is there a clear measure of population attributable risk (PAR) for health and the development of human capital ?

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How is DOHaD affecting policy? Dr. Chessa Lutter Principal Advisor Santiago de Chile, November 19-22, 2009

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  1. . • . How is DOHaD affecting policy? Dr. Chessa Lutter Principal Advisor Santiago de Chile, November 19-22, 2009

  2. What does it take for DOHaD to influence policy? • Is there a clear measure of population attributable risk (PAR) for health and the development of human capital? • Have interventions been identified that are efficacious and effective when delivered through existing health and social service platforms? • Do the interventions address social inequities in health and human capital? • Has there been an effective advocacy strategy to influence relevant technical and political agendas? • Was the strategy successful?

  3. Epigenetics? Concordant developmental changes in DNA methylation across chromosome 2 in two P21 vs P0 mouse hypothalamus MSAM cohybridizations Cohybridization 1 Cohybridization 2 Wenjuan Zhang courtesy of Robert Waterman

  4. It’s a FAT FAT WORLD FAT Kids Urban dog: too fat to walk? Urban black bear behind fast-food restaurant: the new couch potato? FAT Daddys

  5. What proportion of adult disease is explained by DOHaD versus the environment in which we live and eat and move (or don’t move enough)? Developmental origins of adult disease Obesigenic environment Interaction ? Wenjuan Zhang courtesy of Robert Waterman

  6. Severe acute malnutrition Stunting 8.1 cm Marasmas Kwashiorkor Age: 2 y 9 m Weight: 10.7 kg. Height: 78.3 cm 2 y 6 m 11.6 kg 86.4 cm Photo credit: Lancet Photo credit: UNICEF, Perú

  7. Critical period to prevent linear growth retardation 0.5 0.5 0 0 -0.5 -0.5 -1 -1 -1.5 -1.5 -2 -2 -1 + 2 years -1 y + 2 Z -2.5 0 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Age (months) Africa Latin America and Caribbean Asia Source: Shrimpton, R. et al, 2001. http://www.pediatrics.org/cgi/content/full/107/5/e75

  8. Prevalence of stunting to low weight for age (<-2 DS) in children < 5 years % 3.0 6.2 4.5 Source: OPS. Desnutrición en Infantes y Niños Pequeños en América Latina y El Caribe: Alcanzando los Objetivos del Desarrollo del Milenio. Washington: 2008

  9. Distribution of Z scores of Guatemalan children < 5 years (2002) Weight/age Weight/length Length/age Obese Stunted

  10. Tendencies in the prevalence of stunting, by country and year of survey 2008 1989 1994 1998 2003 1986 1995 2000 2005 1986 1991 1996 2002 1987 1995 1999 2002 1995 2000 2005 1986 1996 2000 2007 Source: OPS. Malnutrición en infantes y niños pequeños en América Latina y El Caribe: Alcanzando los Objetivos de Desarrollo del Milenio. Washington DC. 2008

  11. Prevalence of stunting by year of survey and maternal education =59.3% =62.3% Source: OPS. Malnutrición en infantes y niños pequeños en América Latina y El Caribe: Alcanzando los Objetivos de Desarrollo del Milenio. Washington DC. 2008

  12. Short-term consequences Mortality, morbidity, disability Long-term consequences: Adult size, intellectual ability, economic productivity, reproductive performance, metabolic CHD Maternal and child undernutrition Immediate causes Inadequate dietary intake Disease Household food insecurity Unhealthy hh environment & lack of health services Inadequate care Income poverty: Employment, self-employment, dwelling, assets, remittances, pensions, transfers, etc Underlying causes Lack of capital: financial, human, physical, social, and natural Basic causes Social, economic, and political context UNICEF Conceptual model

  13. The role of infectious disease in child growth Source: Mata L. The Children of Santa Maria Caique, 1983.

  14. Policy driver: The effect of malnutrition and human capital The causal relationship between poverty and malnutrition The causal relationship between malnutrition and poverty INCAP longitudinal study and work of Reynaldo Martorell

  15. Decline in the prevalence of stunting in Brazil, 1996-2006 50% 1996 2006 Source: Monteiro et al., Causes for the decline in child undernutrition in Brazil, 1996-2007 Rev Saude Pública 2009;43(1)

  16. Explanatory factor for the decline in stunting in Brazil, 1996-2006 =63.3% Source: Monteiro et al., Causes for the decline in child undernutrition in Brazil, 1996-2007 Rev Saude Pública 2009;43(1)

  17. Breastfeeding Photo credit: João Aprigio Guerra de Almeida, Fundación Fiocruz, Brasil

  18. Breastfeeding promotion cited as the most effective preventive intervention to prevent under-5 mortality From Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? The Lancet 2003;362:65-71.

  19. The importance of health worker training and counseling on exclusive breastfeeding 3 months 5 months 10-180 days 6 months % Source: OPS. Malnutrición en los niños pequeños en América Latina y el Caribe: Alcanzando los Objetivos de Desarrollo del Milenio. Washington 2008.

  20. Effects on human capital development Washington Post 2002; Mortenson et al., 2002 WHO. Horta et al., Geneva 2007. www.who.int/child_adolescent_health/documents/9241595230/en/index.html

  21. Policies and programs to support breastfeeding • International Code of Marketing of Breast-milk Substitutes (WHO 1981) • Innocenti Declaration (1990) and approval at the 45th World Health Assembly • Baby Friendly Hospital Initiative (WHO/UNICEF,1992) • Capacity development in clinical management of common BF problems (USAID financed Wellstart International, 1983-1998) • Global Strategy for Infant and Young Child Feeding and approval by the World Health Assembly (2003) • WHO Child Growth Standards (2006)

  22. Changes in medium duration of breastfeeding:Latin American and Caribbean countries, 1986-2004 17.3 17.3 21.6 21.6 20.6 20.6 14 14 19.6 19.6 20.3 20.3 Months 19.9 19.9 16.2 16.2 20.6 20.6 11.8 11.8 21.6 21.6 9 9 Country

  23. Porcentaje de gasto total (%) y gasto (US$) en la promoción de LM comparado a otros temas en nutrición materno-infantil, 1999-2005 Fuente: Academy for Educational Development. LINKAGES Final Report. Washington DC: 2006. (Expenditures are adjusted for inflation using the Gross Domestic Product Implicit Price Deflator of 2000).

  24. What have we learned and what do we still need to know? 0.5 0.5 0 0 -0.5 -0.5 -1 -1 -1.5 -1.5 -2 -2 Maternal nutrition ? -1 y + 2 -1 + 2 years Z -2.5 0 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Age (months) Africa Latin America and Caribbean Asia Source: Shrimpton, R. et al, 2001. http://www.pediatrics.org/cgi/content/full/107/5/e75

  25. What does it take for DOHaD to influence policy? • Is there a clear measure of population attributable risk (PAR) for health and the development of human capital? • Have interventions been identified that efficacious and effective when delivered through existing health and social service platformsor by addressing fundamental political and social inequities? • Do the interventions address social inequities in health and human capital? • Has there been an effective advocacy strategy to influence relevant technical and political agendas? • Was it successful?

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