Nutrition in Children MCH in Developing Countries HSERV/GH 544

Nutrition in ChildrenMCH in Developing Countries HSERV/GH 544 Jonathan Gorstein Clinical Associate Professor Department of Global Health HSERV 544 - Nutrition in Children

Terminology • Hunger – physiological state when food not able to meet energy needs • Malnutrition – impaired development linked to both deficient and excessive nutrient intake • Undernutrition – most common form of malnutrition in developing countries; energy, protein and micronutrients HSERV 544 - Nutrition in Children

Major Nutritional Problems in the World • Protein-energy malnutrition • Obesity • Micronutrient deficiency problems • Iron deficiency anemia • Vitamin A deficiency • Iodine deficiency disorders • Zinc deficiency • Folate deficiency • Nutrition-related chronic diseases HSERV 544 - Nutrition in Children

Causes of Undernutrition • Undernutrition is a complex condition that involves multiple, overlapping deficiencies of protein, energy and micronutrients – rarely do these occur in isolation • The primary cause of undernutrition is an inadequate food intake, but is compounded by illness and malabsorption • Insufficient access to food, poor health services, the lack of safe water and sanitation, inadequate child and maternal care and poverty are underlying causes HSERV 544 - Nutrition in Children

(UN Lancet 2008: Causal pathways in undernutrition HSERV 544 - Nutrition in Children

Classification of Malnutrition • WHO recommends three anthropometric indicators for assessment of nutritional status • Wasting (Low weight-for-height) • Stunting (Low height-for-age) • Underweight (Low weight-for-age) • Classification based on International Growth Reference HSERV 544 - Nutrition in Children

Chronic Undernutrition - 195 Million under-fives in the developing world are stunted - 80% of them live in just 24 countries Source: UNICEF Global Database, Nov 2009 Compiled from MICS, DHS and other national surveys HSERV 544 - Nutrition in Children

Intergenerational Cycle of Undernutrition The cycle of poor nutrition perpetuates itself across generations - supported by scientific evidence Childhood: Child growth failure, impaired mental development Fetal and Infant stages: Low birthweight baby Pregnancy Compromised nutritional status Adolescents: Low weight and height Adult: Small adult woman, lowered productivity HSERV 544 - Nutrition in Children

Impact of Undernutrition • Increased risk of dying from infectious diseases • Stunting is associated with reduced school performance and lower income earning capacity (22% average; up to 45% has been reported!) • Increased risk of non-communicable diseases in adult life • Reduced GNP by 2-3% • About 20 million children suffer from severe acute malnutrition which greatly increases risk of death HSERV 544 - Nutrition in Children

Infection-Malnutrition Synergism Weight loss Growth faltering Immunity lowered Inadequate dietary intake Disease Incidence Severity Duration Appetite loss Nutrient loss Malabsorption Altered Metabolism HSERV 544 - Nutrition in Children

Causes of Mortality among Preschool Children, 2005 Other Perinatal Deaths associated with undernutrition 55% HIV/AIDS Acute Respiratory Infection Measles Malaria Diarrhea Source: WHO (2003) HSERV 544 - Nutrition in Children

Micronutrients • Micronutrients are needed by the body only in minute amounts, are critical for: • Regulation of growth, activity, development • Immune and reproductive function • Three primary micronutrient deficiencies include: • Iodine • Vitamin A • Iron HSERV 544 - Nutrition in Children

Population at Risk of Deficiency - Global 2.0 1.6 0.8 Source: UNICEF (2002) HSERV 544 - Nutrition in Children

Iodine Deficiency Disorders (IDD) • Single most important cause of preventable brain damage and mental retardation • Significantly raises the risk of stillbirth and miscarriage in pregnant women • About 50 million people worldwide suffer from varying degrees of brain damage and physical impairment due to iodine deficiency – Concept of IDD (Spectrum of disability) • The primary intervention for the control of IDD is through salt iodization HSERV 544 - Nutrition in Children

Iodine Deficiency Disorders (IDD) Today • Some 70 per cent of households in the developing world are using iodized salt, compared to less than 20 per cent at the beginning of the decade. • As a result, 91 million newborns are protected yearly from significant loss in learning ability • Unfinished Business • There are still 35 countries where less than half the households consume iodized salt HSERV 544 - Nutrition in Children

Vitamin A Deficiency • Contributing factor in 2.2 million deaths each year from diarrhea and 1 million deaths from measles among preschool children under five • Severe deficiency can also cause irreversible corneal damage, leading to partial or total blindness • Results of field trials indicate that VA supplementation of children with can reduce deaths from diarrhea. Four studies showed deaths were reduced by 35-50 per cent. • VA can reduce by half the number of deaths due to measles HSERV 544 - Nutrition in Children

Magnitude of Vitamin A Deficiency • Pre-school children • Clinically deficient: 3 million (Asia and Africa) • Subclinically deficient (low serum retinol): 100-140 million • 250,000-500,000 become blind each year • 90 % case fatality among those who become blind • Pregnant women • 25%-30% cases of night blindness reported in some Asian countries HSERV 544 - Nutrition in Children

Interventions to Control VAD • In 1999, only 10 countries provided two rounds of VA supplementation with high coverage, this has increased to over 50 countries by 2004. • Between 1998 and 2004, UNICEF estimates that about two million child deaths may have been prevented from vitamin A supplementation • Food Fortification - A number of countries are successfully fortifying staple foods with vitamin A (e.g. sugar, maize flour, wheat) reaching large populations. HSERV 544 - Nutrition in Children

Iron Deficiency and Anaemia • Most common nutritional disorder in the world • Lowers resistance to disease and weakens a child's learning ability and physical stamina • Significant cause of maternal mortality, increasing the risk of hemorrhage and infection during childbirth. • Nearly 2 billion people estimated to be anemic and millions more are iron deficient, the vast majority are women. • Supplementation and fortification are primary interventions to improve iron intake HSERV 544 - Nutrition in Children

Global Prevalence of Anaemia:Pregnant Women Source: WHO (1999) HSERV 544 - Nutrition in Children

Main Factors Contributing to Anaemia • Iron deficiency • Poor bioavailability of consumed iron • Insufficient dietary iron intake • Chronic and recurrent infections that interfere with food intake and absorption/utilization of iron • Helminth infections, primarily Hookworm • Chronic diarrheal disease • HIV • Malaria HSERV 544 - Nutrition in Children

Interventions to Control Anaemia • Depends on etiology • For iron deficiency: supplementation and fortification • For parasitic disease control: appropriate measures for prevention and presumptive treatment HSERV 544 - Nutrition in Children

“Nutrition-sensitive programming” -- moving from a narrow “nutrition lens” to a wider “development lens” Multi-sectoral nutrition lens Narrow nutrition lens Social welfare sector Financial and credit sector Agriculture sector Health sector Education sector Private sector Trade and tax policies sector Multiple other sectors Financing envelope HSERV 544 - Nutrition in Children

Multi-sectoral programs - Priority intervention areas Increase micronutrient intake Improve breastfeeding and complementary feeding Health Nutrition Micronutrient supplementation and fortification Exclusive breastfeeding Complementary feeding Increase treatment of severe acute malnutrition Care Treatment SAM Improve hygiene and parasite control Improve availability and diversity of food and support livelihoods Household water treatment Local food production Hand washing with soap Transfers and safety nets Bed nets and intermittent preventive treatment Food security Strengthening smallholder farmers Deworming Supplementary feeding Interventions are proven and known to be effective. The challenge is to scale them up

Home Fortification: Reaching Target Groups • Objective: Provide additional vitamins and minerals to a diet based exclusively on cereals • Challenge: Identifying and reaching those in need • Access: Where do caregivers access products and health services • Considerations for free distribution • Examples of distribution models • Free of charge to consumers (public distribution) • Subsidized to consumers (market based) • Consumers pay full price (market based) HSERV 544 - Nutrition in Children

Types of delivery channels for Sprinkles Public distribution Consumer purchasing Beneficiaries purchase and bear full cost of product Hybrid • Free of charge to beneficiaries through clinics and public distribution channels • Subsidized Support to • Production • Storage • Social marketing • Vouchers • Conditional cash transfers HSERV 544 - Nutrition in Children

Example of Hypbrid Model: Renata-BRAC Pushtikona Model type: subsidized & consumers pay full price • Renata (pharmaceutical) + BRAC (NGO) • MNPs sold through Renata pharmacies and usual distribution as well as BRAC Shasthya Shebitka female sales persons • In Bangladesh, MNPs are registered as a pharmaceutical • Possible to market HSERV 544 - Nutrition in Children

Strengths of Model: Renata-BRAC • BRAC is biggest NGO in the world • Guaranteed demand leads to decreased costs • BRAC distribution network is extensive and national • Income generation for women • Builds off Danone-Grameen Project (Fortified yougurt) HSERV 544 - Nutrition in Children

Thank you HSERV 544 - Nutrition in Children

Nutrition in Children MCH in Developing Countries HSERV/GH 544