Leveraging Opportunities inInfant Nutrition                           Dr. Sanjeev Ganguly                     Medical Dire...
Top 10 countries for numbers of stillbirths,                      neonatal and maternal deaths                            ...
We live in a World with LargeInequalities                       Population                       Income
Germany: The Melander family of Bargteheide     Food expenditure for one week US $500
Ecuador: The Ayme family of TingoFood expenditure for one week US $31.55
Chad: The Aboubakar family of Breidjing Camp     Food expenditure for one week US $1.23
India• One of the most malnourished countries in the World.• > 40% of the World’s under weight children below five years l...
Nutrition Interventions• Coverage of essential nutrition interventions is  low ~ 30-40% (Menon2009)• ICDS: new evidence to...
Facts :• More than 4 out of every 10 children in Mumbai, Meerut,  and Delhi are stunted.• Underweight is much more prevale...
Trends in Malnutrition Among Children          Under Three Years
Poor Nutrition as a Contributing Factor to          Under-Five Mortality
Inter-generational Cycle of Malnutrition and Ill Health                                                             •No ex...
Opportunities• Preterm Nutrition  – In NICU  – Post Discharge  – HMF• Especialized Nutrition for IUGR babies ?• 0-6 months...
Opportunities – FunctionalBenefits•   Growth & Development•   Digestion•   Immunity•   Allergy Prevention•   Allergy Manag...
ROLE OF IMMUNONUTRIENTS
IMPACT OF NUTRITIONALDEFICIENCY ON IMMUNITY  • Nutritional deficiency is commonly associated    with impaired immune respo...
ROLE OF NUTRIENTS ON IMMUNE SYSTEM  • The immune system is undergoing permanent renewal    and produces millions of immune...
FATTY ACIDS AND THE IMMUNE SYSTEM • Feeding EPA and DHA has been shown to   modulate specific functions of innate and   ac...
MECHANISMS RESPONSIBLE FOR THE ROLE OFLONG CHAIN N-3 PUFA ON IMMUNE FUNCTION
• compared with Formula-fed infants, the Formula+LCP  infants had a higher % of CD3+CD44+and CD4+CD28+  cells and cytokine...
VITAMIN A AND THE IMMUNE SYSTEM • The importance of vitamin A in immune   function and protection against infections is   ...
VITAMIN A AND THE IMMUNE SYSTEM • Vitamin A supplements has been found to   improve the antibody titer response to   measl...
MECHANISMS RESPONSIBLE FOR THE ROLEOF VITAMIN A ON IMMUNE FUNCTION
• “43 randomized trials representing 215,633  children, shows that giving vitamin A capsules  to children aged 6 months to...
IRON AND IMMUNE SYSTEM• Iron regulates the function of T lymphocytes, and  in most studies (in vivo and in vitro), a defic...
MECHANISMS RESPONSIBLE FOR THEROLE OF IRON ON IMMUNE FUNCTION
• “Significantly lower levels of T lymphocytes as  well as CD4+ cells was observed in the iron  deficient children (P<0.01...
ZINC AND IMMUNE SYSTEM• Zn deficiency impedes host-defense systems  leading to increased susceptibility to a variety  of p...
MECHANISMS RESPONSIBLE FORTHE ROLE OF ZINC ON IMMUNE FUNCTION
• “Children who received a zinc supplement had fewer  episodes of diarrhea (rate ratio: 0.86) and respiratory  tract infec...
• “Zinc supplementation decreased the proportion  of diarrhoeal episodes which lasted beyond 7  days, risk of hospitalizat...
• “six trials and 7850 participants ….analysis  showed that zinc supplementation reduced the  incidence of pneumonia by 13...
NUCLEOTIDES AND IMMUNE SYSTEM • Nucleotides may become conditionally essential during   growth and immunological challenge...
MECHANISMS RESPONSIBLE FOR THE ROLEOF NUCLEOTIDES ON IMMUNE FUNCTION  • Nucleotides contribute to the pool of    nucleotid...
• Systematic review and meta-analysis showed that  ribonucleotide-supplemented infant formulae were  associated with a bet...
PROBIOTICS AND IMMUNE SYSTEM • Probiotics are live microbial food   supplements, which beneficially affect the   host by i...
• “Infants consuming formula with Bb12  produced feces with detectable presence of  Bb12 and augmented sIgA concentration”
VITAMIN C AND THE IMMUNE SYSTEM• Vitamin C is an essential component of every  living cell. Vitamin C is highly concentrat...
MECHANISMS RESPONSIBLE FOR THE ROLEOF VITAMIN C ON IMMUNE FUNCTION
VITAMIN E AND SELENIUM ANDTHE IMMUNE SYSTEM • Vitamin E and the trace element selenium (Se)   function synergistically (by...
MECHANISMS RESPONSIBLE FOR THE ROLE OFVITAMIN E AND SELENIUM ON IMMUNE FUNCTION
• Intervention: One year of fortified milk providing  additional 7.8 mg zinc, 9.6 mg iron, 4.2 g  selenium, 0.27 mg copper...
Challenges• Activism is a major challenge• Regulations are archaic  – Zn is a contaminant as per Food Laws  – Low levels o...
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Leveraging Opportunties in Infant Nutrition in india_2012

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Presentations from Nutraceuticals India, held in October 2012 and provided by conference organiser UBM India.

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Leveraging Opportunties in Infant Nutrition in india_2012

  1. 1. Leveraging Opportunities inInfant Nutrition Dr. Sanjeev Ganguly Medical Director-South Asia Nestle Nutrition
  2. 2. Top 10 countries for numbers of stillbirths, neonatal and maternal deaths Ranking for neonatal Ranking for Ranking for deaths maternal deaths stillbirths India 1 1 1 Nigeria 2 2 3 Pakistan 3 1.5 million 8 178,000 2 1.77 China 4 neonatal 13 maternal 8 million deaths deaths stillbirths DR Congo 5 3 6 Ethiopia 6 Approx 5 Approx 5 Approx 67% 65% 63% Bangladesh 7 6 4 of global of global of global Indonesia 8 total 7 total 7 total Afghanistan 9 4 12 Tanzania 10 9 11Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Stillbirths from Cousens et al 2010 Updated Aug 2010
  3. 3. We live in a World with LargeInequalities Population Income
  4. 4. Germany: The Melander family of Bargteheide Food expenditure for one week US $500
  5. 5. Ecuador: The Ayme family of TingoFood expenditure for one week US $31.55
  6. 6. Chad: The Aboubakar family of Breidjing Camp Food expenditure for one week US $1.23
  7. 7. India• One of the most malnourished countries in the World.• > 40% of the World’s under weight children below five years live in India (Global Hunger Index 2007)• The NFHS 3 - not much progress achieved in improving human resources.• Poverty is a major, but not the only cause of malnutrition• Percentage of population suffering from various forms of malnutrition, far exceeds the percentage below poverty line• After National Nutrition Policy 1993 and National Plan of Action, 1995 no national programs or policies for eradicating malnutrition have appeared.• Today, no national program specifically to combat malnutrition
  8. 8. Nutrition Interventions• Coverage of essential nutrition interventions is low ~ 30-40% (Menon2009)• ICDS: new evidence to show positive impacts, but could be much more efficient (Kandpal2011)• MMS: good impacts on nutrition (Singh 2008), but wrong age group (4-5 year olds) for early under nutrition• ASHA: promising (Ved2011) but no impact studies yet and recruitment and support systems need strengthening
  9. 9. Facts :• More than 4 out of every 10 children in Mumbai, Meerut, and Delhi are stunted.• Underweight is much more prevalent in slum areas than non- slum areas• More than half (54 percent) of all deaths before age five years in India are related to malnutrition.• Because of its extensive prevalence in India, mild to moderate malnutrition contributes to more deaths (43 percent) than severe malnutrition (11 percent).• Seven out of every 10 children age 6-59 months in India are anaemic.
  10. 10. Trends in Malnutrition Among Children Under Three Years
  11. 11. Poor Nutrition as a Contributing Factor to Under-Five Mortality
  12. 12. Inter-generational Cycle of Malnutrition and Ill Health •No excl. BF•Poor fetal nutrition •Delayed /Poor•Poor mother nutrition complementary feeding•No / poor Low Birth •Inadequate foodsupplementation Weight •Infection & healthcare•Gender discrimination •Poor growth catch-up•Infection & healthcare N U T Malnourished R I Stunted Child Mother T I O N•Early Marriage •Poverty•Poor Nutrition •Poor Nutrition•Short inter-pregnancy •Awareness & Education Malnourished Girlgap •Infection & Healthcare•Low BMI facility•Gender discrimination •Gender discrimination Courtsey : Veena S Rao
  13. 13. Opportunities• Preterm Nutrition – In NICU – Post Discharge – HMF• Especialized Nutrition for IUGR babies ?• 0-6 months – Infant Formula• 6-24 months – Follow up formula – Complementary foods
  14. 14. Opportunities – FunctionalBenefits• Growth & Development• Digestion• Immunity• Allergy Prevention• Allergy Management
  15. 15. ROLE OF IMMUNONUTRIENTS
  16. 16. IMPACT OF NUTRITIONALDEFICIENCY ON IMMUNITY • Nutritional deficiency is commonly associated with impaired immune responses, especially cell-mediated immunity, cytokine production, secretory antibody response and affinity • The proper consumption and absorption of micronutrients (e.g. zinc, iron, selenium, vitamin A, pyridoxine, vitamin E) is essential for optimal immune responses
  17. 17. ROLE OF NUTRIENTS ON IMMUNE SYSTEM • The immune system is undergoing permanent renewal and produces millions of immune cells daily. Immune cell renewal is elevated during infectious disease, and recovery depends on the rate of cell division between the invading microorganism and that of immune cells. • The immune system uses both macro and micronutrients involved in DNA, RNA and protein synthesis. • Under-nutrition has a strong influence on the immune system at all ages but mainly in growing and aged humans, i.e. when the body’s nutritional reserves are limited.
  18. 18. FATTY ACIDS AND THE IMMUNE SYSTEM • Feeding EPA and DHA has been shown to modulate specific functions of innate and acquired immunity. • Feeding high levels (>10% of total fat) of n-3 PUFA (compared with diets high in n-6 PUFA) to healthy animals or human subjects results in suppression of the ability of lymphocytes to respond to mitogen stimulation, NK cell activity, and delayed- type hypersensitivity (DTH) reactions
  19. 19. MECHANISMS RESPONSIBLE FOR THE ROLE OFLONG CHAIN N-3 PUFA ON IMMUNE FUNCTION
  20. 20. • compared with Formula-fed infants, the Formula+LCP infants had a higher % of CD3+CD44+and CD4+CD28+ cells and cytokine profile (lower production of TNF-a post- stimulation) that did not differ from HM infants.• “feeding infants formula during the first 10 d of life influenced immune function… infants had a higher percentage of CD3+, CD4+CD28+, and lower percentage of CD14+ cells and produced more TNF-a and interferon-g after PHA stimulation than HM-fed infants (P,0·05).
  21. 21. VITAMIN A AND THE IMMUNE SYSTEM • The importance of vitamin A in immune function and protection against infections is well-established • Vitamin A deficiency can affect host defenses directly through its essential functions in metabolism in the various immune cells or indirectly through its role in epithelial cell differentiation and host barrier function
  22. 22. VITAMIN A AND THE IMMUNE SYSTEM • Vitamin A supplements has been found to improve the antibody titer response to measles vaccines, maintain gut integrity, lower the incidence of respiratory tract infections, and reduce mortality associated with diarrhea and measles
  23. 23. MECHANISMS RESPONSIBLE FOR THE ROLEOF VITAMIN A ON IMMUNE FUNCTION
  24. 24. • “43 randomized trials representing 215,633 children, shows that giving vitamin A capsules to children aged 6 months to 5 years can reduce death and some diseases”• “death due to measles, respiratory infections or meningitis was not specifically reduced, but vitamin A can reduce new occurrences of diarrhoea and measles”
  25. 25. IRON AND IMMUNE SYSTEM• Iron regulates the function of T lymphocytes, and in most studies (in vivo and in vitro), a deficiency results in impaired cell-mediated immunity.• Iron deficiency may also delay the development of cell-mediated immunity• Neutrophil function (decreased myeloperoxidase activity and bactericidal activity) and NK activity are impaired with iron deficiency
  26. 26. MECHANISMS RESPONSIBLE FOR THEROLE OF IRON ON IMMUNE FUNCTION
  27. 27. • “Significantly lower levels of T lymphocytes as well as CD4+ cells was observed in the iron deficient children (P<0.01 and 0.002 respectively). The CD4 : CD8 ratio was also significantly lower in this group (P<0.05)”• “Iron supplementation improved the CD4 counts significantly”
  28. 28. ZINC AND IMMUNE SYSTEM• Zn deficiency impedes host-defense systems leading to increased susceptibility to a variety of pathogens, and a deficiency of Zn is known to occur in many diseased states that involve the immune system like alcoholism, renal disease, burns, gastrointestinal tract disorders and diarrhea
  29. 29. MECHANISMS RESPONSIBLE FORTHE ROLE OF ZINC ON IMMUNE FUNCTION
  30. 30. • “Children who received a zinc supplement had fewer episodes of diarrhea (rate ratio: 0.86) and respiratory tract infections (rate ratio: 0.92) and significantly fewer attacks of severe diarrhea or dysentery (rate ratio: 0.85), persistent diarrhea (rate ratio: 0.75), and lower respiratory tract infection or pneumonia (rate ratio: 0.80) than did those who received placebo. They also had significantly fewer total days with diarrhea (rate ratio: 0.86)”
  31. 31. • “Zinc supplementation decreased the proportion of diarrhoeal episodes which lasted beyond 7 days, risk of hospitalization, all-cause mortality and diarrhoea mortality”• “…zinc for the treatment of diarrhoea is estimated to decrease diarrhoea mortality by 23%”
  32. 32. • “six trials and 7850 participants ….analysis showed that zinc supplementation reduced the incidence of pneumonia by 13% and prevalence of pneumonia by 41%”• “subgroup analysis…zinc reduced the incidence of pneumonia defined by specific clinical criteria by 21%”
  33. 33. NUCLEOTIDES AND IMMUNE SYSTEM • Nucleotides may become conditionally essential during growth and immunological challenges when demand may exceed de novo synthetic capacity • The addition of nucleotides to nucleotide-free diets has been shown to reverse or restore many of the changes observed with nucleotide deficiency, such as increasing Th1-type cytokines, increasing antibody production, and increasing spleen cell proliferation. • Human infants fed breast milk or formula supplemented with nucleotides had higher NK cell activity and IL-2 production compared with infants fed formula without nucleotides.
  34. 34. MECHANISMS RESPONSIBLE FOR THE ROLEOF NUCLEOTIDES ON IMMUNE FUNCTION • Nucleotides contribute to the pool of nucleotides available to immune cells • Nucleotides are building blocks for DNA and RNA synthesis and are involved in diverse cellular processes, serving as sources of chemical energy [e.g., 5-triphosphate (ATP)] and intracellular signals (e.g., adenosine cyclic 3,5-adenosine monophosphate and cyclic 35- guanosine monophosphate)
  35. 35. • Systematic review and meta-analysis showed that ribonucleotide-supplemented infant formulae were associated with a better antibody response to immunisation with Haemopillus influenzae vaccine [SMD 1·74 (99 %CI 1·43–2·05), P = 0·001], diphtheria toxoid [SMD 0·94 (0·75–1·12), P = 0·001], oral polio vaccine [SMD 0·73 (0·51–0·95), P =¼ 0·001], and fewer episodes of diarrhoea [RR 0·67 (0·58–0·76),P = 0·02]
  36. 36. PROBIOTICS AND IMMUNE SYSTEM • Probiotics are live microbial food supplements, which beneficially affect the host by improving its intestinal microbial balance. • Recent evidence indicates that probiotics (e.g. bifidobacterium and Lactobacillus species) may influence both systemic and gut- associated immune responses.
  37. 37. • “Infants consuming formula with Bb12 produced feces with detectable presence of Bb12 and augmented sIgA concentration”
  38. 38. VITAMIN C AND THE IMMUNE SYSTEM• Vitamin C is an essential component of every living cell. Vitamin C is highly concentrated in leukocytes and is used rapidly during infection (e.g., to prevent oxidative damage).• Reduced concentrations of this vitamin in leukocytes is associated with reduced immune function
  39. 39. MECHANISMS RESPONSIBLE FOR THE ROLEOF VITAMIN C ON IMMUNE FUNCTION
  40. 40. VITAMIN E AND SELENIUM ANDTHE IMMUNE SYSTEM • Vitamin E and the trace element selenium (Se) function synergistically (by related but independent mechanisms) in tissues to reduce damage to lipid membranes by the formation of reactive oxygen species (ROS) during infections
  41. 41. MECHANISMS RESPONSIBLE FOR THE ROLE OFVITAMIN E AND SELENIUM ON IMMUNE FUNCTION
  42. 42. • Intervention: One year of fortified milk providing additional 7.8 mg zinc, 9.6 mg iron, 4.2 g selenium, 0.27 mg copper, 156 g vitamin A, 40.2 mg vitamin C, 7.5 mg vitamin E per day• Results: Reduced the odds for days with severe illnesses by 15%, the incidence of diarrhea by 18%, and the incidence of acute lower respiratory illness by 26%
  43. 43. Challenges• Activism is a major challenge• Regulations are archaic – Zn is a contaminant as per Food Laws – Low levels of protein in Preterms – IYCF guidelines outdated• Environmental sanitation & Clean drinking water• Generating evidence on Nutritional solutions
  44. 44. Thank you

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