Thinking about Programming to Reduce Chronic Malnutrition in Infants and Young Children Judy Canahuati, USAID with thanks to Mary Arimond, IFPRI and Martin.

Thinking about Programming Thinking about Programming to Reduce Chronic to Reduce Chronic

Malnutrition in Malnutrition in Infants and Infants and Young ChildrenYoung Children

Thinking about Programming Thinking about Programming to Reduce Chronic to Reduce Chronic

Malnutrition in Malnutrition in Infants and Infants and Young ChildrenYoung Children

Judy Canahuati, USAIDJudy Canahuati, USAID

with thanks to Mary with thanks to Mary Arimond, IFPRI and Martin Arimond, IFPRI and Martin

Bloem, WFPBloem, WFP

Judy Canahuati, USAIDJudy Canahuati, USAID

with thanks to Mary with thanks to Mary Arimond, IFPRI and Martin Arimond, IFPRI and Martin

Bloem, WFPBloem, WFPInteraction, May 9, 2008Interaction, May 9, 2008

Photo: CARE USAPhoto: CARE USA

OutlineOutlineOutlineOutline• Window of opportunity: Window of opportunity:

conception- 24 monthsconception- 24 months• Why does growth falter?Why does growth falter?• Poverty and malnutritionPoverty and malnutrition• 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

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

• Why does growth falter?Why does growth falter?• Poverty and malnutritionPoverty and malnutrition• 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

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)

Rice consumption and rice Rice consumption and rice pricesprices

Torlesse, Kiess and BloemTorlesse, Kiess and Bloem J. Nutr. 133:1320-1325, May 2003J. Nutr. 133:1320-1325, May 2003

Rice consumption and rice Rice consumption and rice pricesprices

Torlesse, Kiess and BloemTorlesse, Kiess and Bloem J. Nutr. 133:1320-1325, May 2003J. Nutr. 133:1320-1325, May 2003

Malnutrition rates and Rice Malnutrition rates and Rice pricesprices

Torlesse, Kiess and BloemTorlesse, Kiess and Bloem J. Nutr. 133:1320-1325, May 2003J. Nutr. 133:1320-1325, May 2003

Malnutrition rates and Rice Malnutrition rates and Rice pricesprices

Torlesse, Kiess and BloemTorlesse, Kiess and Bloem J. Nutr. 133:1320-1325, May 2003J. Nutr. 133:1320-1325, May 2003

Non-rice food expenditure and Non-rice food expenditure and malnutritionmalnutrition

Torlesse, Kiess and BloemTorlesse, Kiess and Bloem J. Nutr. 133:1320-1325, May 2003J. Nutr. 133:1320-1325, May 2003

Non-rice food expenditure and Non-rice food expenditure and malnutritionmalnutrition

Torlesse, Kiess and BloemTorlesse, Kiess and Bloem J. Nutr. 133:1320-1325, May 2003J. Nutr. 133:1320-1325, May 2003

Choices and economic statusChoices and economic statusChoices and economic statusChoices and economic status

Very, very poorVery, very poor

Less poorLess poor

Not poorNot poor

Moderate poorModerate poor

Very poorVery poor

RiceRice

RiceRice RiceRice and vegsand vegs

RiceRice

RiceRice

RiceRice and vegsand vegs RiceRice and eggsand eggs

RiceRice and vegsand vegs RiceRice and eggsand eggs RiceRice and meat and meat

RiceRice RiceRice and vegs and vegsRice,Rice, vegsvegs,, and eggsand eggsRice, Rice, vegsvegs, , eggs,eggs, meat meat

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

Courtesy IFPRICourtesy IFPRI

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., 2008Courtesy IFPRICourtesy IFPRI

Underweight Underweight trends among children* in target areas in trends among children* in target areas in

GINA II countries GINA II countries

Underweight Underweight trends among children* in target areas in trends among children* in target areas in

GINA II countries GINA II countries

MozambiqueMozambique UgandaUganda NigeriaNigeria GINA II GINA II AverageAverage

Baseline Baseline FinalFinal 52% 9% 52% 9%

Baseline Baseline Final Final 21.2 % 10.2% 21.2 % 10.2%

Baseline Baseline FinalFinal 24.6% 22.9%24.6% 22.9%

Baseline Baseline Final Final 32.4 % 32.4 % 14.1%14.1%

82 % 82 % reduction in reduction in severely and severely and moderately moderately underweight underweight childrenchildren*Children <59 months *Children <59 months who have a weight-who have a weight-for-age score below -2 for-age score below -2 SD based on SD based on NCHS/CDC/WHO NCHS/CDC/WHO reference population. reference population.

52% reduction 52% reduction in severely and in severely and moderately moderately underweight underweight childrenchildren

7.5 % 7.5 % reduction in reduction in severely and severely and moderately moderately underweight underweight childrenchildren

57% reduction 57% reduction in severely in severely and and moderately moderately underweight underweight childrenchildren

Chikodzore, Downer Chikodzore, Downer & Tanamly& TanamlyEvaluation GINA IIEvaluation GINA II

Some Nutritional Some Nutritional Programmatic alternativesProgrammatic alternatives

Some Nutritional Some Nutritional Programmatic alternativesProgrammatic alternatives

• Global Strategy for Infant and young Global Strategy for Infant and young child feeding and Family foods for child feeding and Family foods for breastfed child (WHO)breastfed child (WHO)

• ENA (Essential Nutrition Actions)ENA (Essential Nutrition Actions)• AIN (Integral attention to the child)AIN (Integral attention to the child)• WV Preventive MethodWV Preventive Method• GINA II Model of integrating GINA II Model of integrating

agriculture and nutritionagriculture and nutrition• PD/HearthPD/Hearth• CMAM (Community Management of CMAM (Community Management of

Acute Malnutrition)Acute Malnutrition)

• Global Strategy for Infant and young Global Strategy for Infant and young child feeding and Family foods for child feeding and Family foods for breastfed child (WHO)breastfed child (WHO)

• ENA (Essential Nutrition Actions)ENA (Essential Nutrition Actions)• AIN (Integral attention to the child)AIN (Integral attention to the child)• WV Preventive MethodWV Preventive Method• GINA II Model of integrating GINA II Model of integrating

agriculture and nutritionagriculture and nutrition• PD/HearthPD/Hearth• CMAM (Community Management of CMAM (Community Management of

Acute Malnutrition)Acute Malnutrition)

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 playFortified commodities have a role to play• 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 powders and spreadsfor micronutrient powders and spreads22

• Fortified commodities have a role to playFortified commodities have a role to play• 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 powders and spreadsfor micronutrient powders and spreads22

1 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

Summing up…Summing up…Summing up…Summing up…

• Poverty is one of the key Poverty is one of the key determinants of malnutrition.determinants of malnutrition.

• Poor people have limited access Poor people have limited access to micronutrient rich foods (non-to micronutrient rich foods (non-grain component of total food grain component of total food expenditure).expenditure).

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

• Poverty is one of the key Poverty is one of the key determinants of malnutrition.determinants of malnutrition.

• Poor people have limited access Poor people have limited access to micronutrient rich foods (non-to micronutrient rich foods (non-grain component of total food grain component of total food expenditure).expenditure).

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

Summing up…(cont.)Summing up…(cont.)Summing up…(cont.)Summing up…(cont.)

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

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

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

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