Lancet Series Update 2013 By Monica Muti
National Nutrition Technical Update Meeting05-06 August 2013
Kadoma Hotel
Maternal and Child Nutrition 1:
Maternal and child undernutrition and
overweight in low-income and middle-income countries
Aim of this paperAssess the prevalence of nutritional conditions and
their health and development consequencesTo reassess the problems of maternal and child
under-nutritionTo examine the growing problems of overweight
and obesity for women and children and their consequences in low-income and middle-income countries (LMICs).
To assess national progress in nutrition programmes
To assess international actions consistent with previous recommendations
Framework shows the means to optimum fetal and child growth
and development, rather than the determinants of undernutrition
framework shows the dietary, behavioural, and health determinants of optimum nutrition, growth, and development and how they are affected by underlying food security,
caregiving resources, and environmental conditions, which are in turn shaped by economic and social conditions, national and global contexts, resources, and governance.
This Series examines how these determinants can be changed to enhance growth and development.
Framework for action to achieve optimum fetal and child nutrition and development
Adolescent Nutrition1.2 billion adolescents (12-19years) in the world
90% live in low to middle income countries(LMIC)Potential for catch up growth of stunted children??Adolescent fertility three times higher in LMICs than in
high-income countries.Pregnancies in adolescents
higher risk of complications and mortality in mothers and children
poorer birth outcomes slow and stunt a girl’s growth.
In some countries, as many as half of adolescents are stunted, 11% thin, 5% obese
High prevalence of anaemia
Maternal NutritionPrevalence of over weight (BMI ≥25 kg/m2) and obesity
(BMI ≥30 kg/m2)rising in all regions (more than 40% in Africa by 2008)
Obese pregnant women four times more likely to develop gestational diabetes
mellitus and two times more likely to develop pre-eclampsia
During labour and delivery, maternal obesity is associated with maternal death, haemorrhage, caesarean delivery, or
infection;29–31 and a higher risk of neonatal and infant death
MUAC in pregnancy inversely associated with all cause mortality up to 42 days postpartum(one study)
Inverse association between maternal height and the risk of dystocia (difficult labour)
Anaemia and IronAmong pregnant women with anaemia at baseline,
iron supplementation led to a 10・ 2 g/L increase in haemoglobin (8・ 0 g/L in children)
20% reduction in the risk of low birth weight associated with antenatal supplementation with iron alone or combined with folic acid
Risk of death of children younger than 5 years reduced by 34% when the mother consumed any iron-folic acid supplements (Dibley et.al)protective effect greatest for deaths on the first day
of life
Vitamin A and ZincPrevalence of night blindness in pregnant
women estimated to be 7・ 8%night blindness known to be associated with a
four-times higher odds of low serum retinolMaternal night blindness associated with
increased low birth weight and infant mortalitytrials of vitamin A in pregnancy not showed
significant effects on these outcomes17% of the world’s population at risk of zinc
deficiency Based on analysis of national diets
Iodine and Folate28.5% of the world’s population estimated to
be iodine deficientReview of the effects of iodine
supplementation in deficient populations showed a small increase in birth weight
Substantial proportion of neural tube defects related to inadequate consumption of folic acid around the time of conceptionfive trials of folic acid (a synthetic form of
folate) supplementation identified a 72% reduction in the risk of neural tube defects
Childhood NutritionStunting - decreased from an estimated 40% in
1990, to an estimated 26% in 2011Underweight - 16% ( 36% decreased from 1990)Wasting – 8% (11% decrease from 1990)Suboptimum growth shown to increase the risk
of death from infectious diseases in childhoodStunting and underweight with highest proportion
of attributed child deaths (14%)Overweight – 4% to 11% in Africa (projected to
reach 11% in 2025)strong risk factor for adult obesity and its
consequences
Determinants of childhood stunting and overweightPromotion of appropriate complementary
feeding practices reduces the incidence of stunting
Diarrhoea is the most important infectious disease determinant of stunting of linear growth25% of stunting attributed to five previous
episodes of diarrhoeaOptimum growth in the first 1000 days of life
essential for prevention of overweightrapid weight gains in the first 1000 days
strongly associated with adult lean mass
Conclusion to paper 1Evidence supports focus on pregnancy and the first 2 years
of lifeMore emphasis to the nutritional conditions
in adolescence, at the time of conception, and during pregnancy, as important for maternal health and
survival, fetal growth and sub sequent early childhood survival, growth, and development.
Fetal growth restriction and poor growth early in infancy now recognised as important determinants of neonatal and infant mortality, stunting, and overweight and obesity in older children and adults
Preventive efforts should continue to focus on the 1000 daysTherapeutic efforts should continue to target severe
wasting.
Maternal and Child Nutrition 2
Evidence-based interventions for improvement of maternal and child nutrition: what can
be done and at what cost?
Background Update of interventions to address under-
nutrition and micronutrient deficiencies in women and children
Current total of deaths in children younger than 5 years can be reduced by 15% if populations can access ten evidence-based nutrition interventions at 90% coverage
About a fifth of the existing burden of stunting can be averted using these approaches, if access is improved in this way
Interventions to address adolescent health and nutritionReproductive health and family planning
interventionsto reduce unwanted pregnancies to optimise age at first pregnancy
Community and school-based education platformsTo address micronutrient deficiencies To address emerging issues of overweight and
obesity in adolescents
Interventions in women of reproductive age and during pregnancyFolic acid supplementationReview of folic acid supplementation during
pregnancyIncrease in mean birth weight79% reduction in incidence of megaloblastic
anaemiaLogistical challenges in reaching women of
reproductive age in the peri-conceptual period Fortification of cereals and other foods a
possible solution
Interventions in women of reproductive age and during pregnancyIron or iron and folic acid supplementationWHO recommends daily iron supplementation during
pregnancy as part of the standard of care in populations at risk of iron deficiency
Maternal multiple micronutrient supplementationReduction in LBW, SGA, small effect on preterm
birthsPotential for replacement of iron-folate supplements
in pregnancy in populations at riskMaternal calcium supplementationshown to reduce maternal hypertensive disorders and
preterm birth
Interventions in women of reproductive age and during pregnancyMaternal iodine supplementation or
fortificationIodised salt use the most cost-effective way to
avert deficiencyAddressing maternal wasting and food
insecurity with balanced energy and protein supplementation
Balanced energy protein supplementation, providing about 25% of the total energy supplement as proteinLeads to increased birth weight by 73g and
reduced risk of SGA by 34%
Nutrition interventions in neonatesDelayed cord clamping
Significant increase in newborn haemoglobin Higher serum ferritin concentration at 6
months of ageNeonatal vitamin K administrationNeonatal vitamin A supplementation
Additional data needed before developing recommendations
Kangaroo mother care
Nutrition interventions in infants and childrenPromotion of breastfeeding and supportive
strategiesEarly initiation, EBF to six months, continued BF to
24months or more - global progress both uneven and suboptimal
Education and counselling interventions importantMore needs to be done to assess innovations and
strategies to promote breast feeding in working women
Promotion of dietary diversity and complementary feeding
Nutrition interventions in infants and childrenVitamin A supplementation in children
continues to be an effective intervention in children aged 6–59 months in populations at risk of vitamin A deficiency
Iron supplementation in infants and children
Multiple micronutrient supplementation in children
Preventive zinc supplementation in children
Disease prevention and managementInpatient treatment for children with
complicated SAMCommunity-based care for uncomplicated
SAMprogrammatic evidence supports use of RUTF
for community-based treatment
Conclusion Scaling up to 90% coverage associated with
15% reduction in under five mortalityLittle effect on maternal mortalityMean 20.3% (range 11・ 1–28・ 9) reduction in
stunting 61・ 4% (35・ 7–72) reduction in severe wasting
Interventions with the largest potential effect on mortality in children younger than 5 years:Management of SAMPreventive zinc supplementationPromotion of breastfeeding