2 nutrition and lifestages

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2 nutrition and lifestages

  1. 1. Nutrition Through the Lifecycle Maternal Nutrition Low Birth weight
  2. 2. Why focus on women’s nutrition? • First and foremost because women have a basic right to food security and good health • However, due to their multiple roles of reproducing, nurturing, caring and producing, the social, economic, health and development implications of women’s malnutrition can be devastating
  3. 3. Why focus on women’s nutrition?... • Consequences include  Infections  Obstructed labor  Low birth weight  Neonatal and infant mortality  Maternal mortality  Undernourished mothers are less productive and this has economical implications as well as implications for household food security
  4. 4. What is and why the lifecycle approach?
  5. 5. The Typical Scenario in Africa A woman enters pregnancy undernourished, anemic and probably deficient in other micronutrients → She gives birth to an infant with LBW who immediately starts life at a disadvantage → → childhood and adolescence → → The female adolescent enters womanhood & pregnancy malnourished….and the cycle continues!
  6. 6. The Lifecycle approach…why? • Focusing on female nutrition throughout the lifecycle – from infancy through childhood to adolescence and the reproductive years may give greater dividends in terms of improved nutritional status of both mother and child
  7. 7. The Lifecycle approach…why?... • The benefits spill over to the elderly who because of nutritional investments throughout the lifecycle are healthier in later years • Elderly are a major resource for the care of infants and young children • Healthier elders could translate into improved quality of care for infants and young children while reducing the burden of women in caring for sick elders
  8. 8. UNICEF/C-79-15/Goodsmith • Maternal Nutrition • Major Issues
  9. 9. Maternal Malnutrition: A Life-Cycle Issue  Infancy and early childhood (0-24 months) – Suboptimal breastfeeding practices – Inadequate complementary foods – Infrequent feeding – Frequent infections  Childhood (2-9 years) – Poor diets – Poor health care – Poor education
  10. 10. Maternal Malnutrition: A Life-Cycle Issue…  Adolescence (10-19 years) – Increased nutritional demands – Greater iron needs – Early pregnancies  Pregnancy and lactation – Higher nutritional requirements – Increased micronutrient needs – Closely-spaced reproductive cycles
  11. 11. Maternal Malnutrition: A Life-Cycle Issue…  Throughout life – Food insecurity – Inadequate diets – Recurrent infections – Frequent parasites – Poor health care – Heavy workloads – Gender inequities
  12. 12. The Intergenerational Cycle of Malnutrition Child growth failure Early pregnancy Small adult women Low birth weight babies Low weight and height in teens ACC/SCN, 1992
  13. 13. Maternal Malnutrition… • Women who were malnourished as infants are more likely to give birth to malnourished babies • Infant malnutrition, especially for girls, effectively perpetuates poverty, hunger, and malnutrition across generations
  14. 14. Maternal Nutrition and the MDGs • Improved maternal nutrition is essential for attaining many of the MDG targets: – Reducing maternal mortality by three quarters between 1990 and 2015 – Reducing hunger and malnutrition (Goal 1) – Achieving universal education (Goal 2) – Promoting gender equality and women’s empowerment (Goal 3)
  15. 15. Mechanism for poverty transmission throughout the life course Poverty is biologically transmitted across generations through malnutrition – Maternal underweight • Key risk factor in low birth weight – Low birth weight • Risk factor for child stunting and underweight
  16. 16. Maternal undernutrition –Chronic energy deficiency –Micronutrient deficiencies
  17. 17. Chronic energy deficiency • Maternal body-mass-index (BMI) = Weight (in kg)/height (in m) squared, • Measure of chronic energy deficiency (CED) – Severe CED : BMI<16 – Mild/moderate CED : BMI 16 - 18.49 – No CED : BMI 18.5 - 24.99 – Overweight : BMI 25 - 29.99 – Obese: BMI >=30
  18. 18. Major Interventions in Maternal Nutrition  Improve weight and height  Improve micronutrient status
  19. 19. Improving Maternal Weight  Increase caloric intake  Reduce energy expenditure  Reduce caloric depletion
  20. 20. Improving Maternal Height  Weight increases can be achieved within a woman’s reproductive life’  May not be true for height  Increase birth weight  Enhance infant growth  Improve adolescent growth
  21. 21. Optimal Behaviors to Improve Women’s Nutrition Early Infancy: Exclusive breastfeeding to about six months of age
  22. 22. Optimal Behaviors to Improve Women’s Nutrition… • Late Infancy and Childhood: – Appropriate complementary feeding from about six months
  23. 23. Optimal Behaviors to Improve Women’s Nutrition… UNICEF/C-56-7/Murray-Lee • Late Infancy and Childhood: Continue frequent on-demand breastfeeding to 24 months and beyond
  24. 24. Optimal Behaviors to Improve Women’s Nutrition… Pregnancy: • Increase food intake • Take iron+folic acid supplements daily • Reduce workload UNICEF/C-55-10/Watson
  25. 25. Optimal Behaviors to Improve Women’s Nutrition UNICEF/C-88-15/Goodsmith Lactation: • Increase food intake • Take a high dose vitamin A at delivery • Reduce workload
  26. 26. Vitamin A Postpartum Supplementation • Recommendations Current (WHO): 200,000 IU in 1 dose, as soon as possible after delivery Proposed: 400,000 IU in 2 doses of 200,000 IU at least 1 day apart, as soon as possible after delivery
  27. 27. Optimal Behaviors to Improve Women’s Nutrition UNICEF90-070/Lemoyne • Delay first pregnancy • Increase birth intervals
  28. 28. Optimal Behaviors to Improve Women’s Nutrition At all times: • Increase food intake if underweight • Diversify the diet • Use iodized salt • Control parasites • Take micronutrient supplements if needed
  29. 29. Improving Women’s Micronutrient Status  Dietary modification  Parasite control  Fortification  Supplementation
  30. 30. Dietary Modification to Improve Women’s Micronutrient Status Increase:  Micronutrient intake  Bioavailability of micronutrient intake
  31. 31. Parasite Control to Improve Women’s Micronutrient Status Reduce parasite transmission:  Improve hygiene  Increase access to treatments
  32. 32. Fortification to Improve Women’s Micronutrient Status Medium-term strategy:  Improves micronutrient intake  Without changing food habits Requires:  Appropriate nutrient fortificant  Appropriate food vehicle
  33. 33. Examples of Micronutrient Food Fortification Vitamin A in sugar Iron in wheat flour Iodine in salt Multiple fortification  iron + iodine in salt  iron + vit B in wheat flour
  34. 34. Supplementation to Improve Women’s Micronutrient Status  Preventive or therapeutic  Daily or periodic  Targeted to groups  Mass distribution
  35. 35. Iron+Folic Acid Supplementation for Women of Reproductive Age Prior to and between pregnancies: Periodic supplementation (60 mg of iron and 400 μg folic acid) daily for 3 months for: ● Girls before puberty and during adolescence ● Women of childbearing age
  36. 36. Elements of a Successful Supplementation Program  Supplement supply  Delivery system  Women’s demand and compliance  Monitoring and evaluation
  37. 37. Supplement Supply  Data-based ordering  Timely procurement process  Timely distribution to delivery points
  38. 38. Supplement Delivery System  Accessible to target population  Appropriate Staff:  Motivated  Approachable  Supportive  Adequately trained
  39. 39. Women’s Demand and Compliance  Communications component  Community awareness  Information on side effects  Good quality supplements
  40. 40. Monitoring and Evaluation  Monitor at all levels:  Supply  Coverage  Compliance  Communications component  Evaluate impact on prevalence
  41. 41. Low Birth Weight (LBW)
  42. 42. Low Birth Weight…. • Birthweight is the first weight of the foetus or newborn obtained after birth. • For live births, birthweight should preferably be measured within the first hour of life, before significant postnatal weight loss has occurred.
  43. 43. LBW - Incidence • The incidence of low birthweight in a population is the percentage of live births that weigh less than 2,500 g out of the total of live births during the same time period.
  44. 44. LBW - Measurement • Data Sources: – Developed countries - service-based data and national birth registration systems – Developing countries - national household surveys, as well as data from routine reporting systems • Since about 1990 from mothers participating in nationally representative household surveys, mostly the USAID supported DHS and the UNICEF-supported MICS.
  45. 45. LBW – Measurement… • Births that were weighed were more likely to involve mothers who were – better educated and resided in urban areas, – in a medical facility and with assistance from skilled health personnel. • These characteristics are generally associated with higher birthweights and, therefore, the resulting estimates were still likely to underestimate the level of low birthweight.
  46. 46. Low birth weight (LBW) – Definition and Magnitude • Birth weight below 2500 grams (5.5 pounds), – 30% in South Asia, – 14% in sub-Saharan Africa, – 15% in Middle East and North Africa, – 10% in Latin America, • Very low birth weight : <1,500 grams
  47. 47. LBW - Significance • Low birth weight infants: – High risk of neonatal or infant mortality, – Less likely to catch-up significantly, – High risk of developmental deficits, – More likely to be underweight or stunted, – Consequences extend into adulthood, • “fetal origins of disease hypothesis”
  48. 48. Causes of LBW • Intrauterine growth retardation (IUGR) – Intrauterine growth that is less than expected for length of gestation – Small for gestational age (SGA) – More common in Developing countries • Preterm birth (<37 weeks) – Short duration of pregnancy – More common in Developed countries
  49. 49. Causes of LBW… – For the same gestational age, girls weigh less than boys, firstborn infants are lighter than subsequent infants, and twins weigh less than singletons; – Birthweight is affected to a great extent by the mother’s own foetal growth and her diet from birth to pregnancy, and thus, her body composition at conception;
  50. 50. Causes of LBW… – Poor maternal nutrition during pregnancy accounts for 14% of IUGR in developing countries – Maternal stunting may account for 18.5%
  51. 51. Causes of LBW… Developing countries; – 50% of all IUGR in rural areas of developing countries attributable to; • small maternal size at conception • low gestational weight gain
  52. 52. Causes of LBW… Other causes of IUGR, developing countries; – Malaria in endemic areas – Maternal infections – Abnormal placental blood flow or structure – Foetal infections
  53. 53. Causes of LBW… Developed countries – Premature delivery – Cigarette smoking during pregnancy – Low gestational weight gain – Low BMI at conception – Maternal undernutrition - uncommon – Folic acid deficiency may increase risk of preterm delivery
  54. 54. Classification of LBW/PTD Gestational age LBW Normal BW >37 weeks IUGR Normal <37 weeks Preterm/ Preterm and/or IUGR
  55. 55. PTD and IUGR as determinants of LBW • Preterm infant may be LBW but have an appropriate weight for its gestational age – LBW only because it was born early • Preterm infant may also be growth retarded – LBW because of both shortened gestation and growth retardation
  56. 56. Three types of IUGR • Group 1: – Born after 37 weeks of gestation and weight less than 2,500 g at birth • Group 2: – Newborns are preterm and weigh less than the 10th percentile at birth • Group 3: – Weigh less than the 10th percentile, but have a birth weight greater than 2,500 g
  57. 57. Types of IUGR
  58. 58. Epidemiology of IUGR • In 2000, an estimated 11.0% of newborns in developing countries, or 11.7 million infants, have low birth weight at term • In Asia, 20.9% of newborns are affected, and the sub-region accounts for 80% of all affected newborns worldwide
  59. 59. IUGR… IUGR affects more newborns than low birth weight; – about 24% or 30 million newborns per year in developing countries • Major global human development problem; – profound short- and long-term consequences for individuals, communities, and whole populations
  60. 60. Consequences of LBW – Increased risk of morbidity and mortality – Poor neurodevelopmental outcomes – Reduced strength and working capacity – Increased risk of chronic diseases in adulthood
  61. 61. LBW - Prevalence and Trend
  62. 62. Low Birth Weight - Trends (2000-2011) 6 21 21 8 14 11 28 7 9 66 72 70 2000 2005 2011 2000 2005 2011 very small smaller than average Average or larger Reported birth weight < 2.5 kg Mothers’ subjective assessment Only 5% of children in Ethiopia are weighed at birth in 2011
  63. 63. Trends in LBW - LBW on the rise between 1976-1996 in Addis Ababa 5.8 7.3 11.3 0 2 4 6 8 10 12 70's 80's 90's PercentLBW Year The odds of LBW in the 90's was 52% higher compared to the 70's
  64. 64. Trends in LBW - Regions Study area Year of Survey Prevalence Gondar 1967 1988 1996 13.8% 11.1% 17.8% Addis Ababa 1997 9.1% Jimma 2003 2005 22.5% 11.0%
  65. 65. LBW and Malaria Study area Sample size Prevalence Gambella (2003) Infected Uninfected With placental malaria Without placental malaria 9 159 44 14 Prevalence of placental malaria: 5% J. Infect. Dis. 187:1765– 1772.
  66. 66. Factors associated with LBW – Teen age pregnancy (<20 years) – Shorter stature (<= 150cm) – Short birth intervals and – Mothers who come late for antenatal visit and had complications during pregnancy. – Infections (Malaria…)(Gebremariam A. East Afr Med J. 2005 Nov;82(11):545-6)
  67. 67. • Infant with Low birth weight • Infancy & childhood up to 5 years - Stunting - Underweight - Wasting • Women Chronic energy deficiency
  68. 68. Nutritional Status of Children Under Age Five
  69. 69. Duration of Breastfeeding by Region >36 >36 26 26 26 25 25 23 22 21 20 Amhara Gambela Tigray SNNP Addis Ababa Affar Oromiya Benishangul-… Somali Harari Dire Dawa
  70. 70. How Does Breastfeeding Differ by Country? 21 21 22 23 23 24 25 26 Uganda 2000-01 Tanzania 2004-05 Kenya 2003 Eritrea 2002 Mozambique 2003 Malawi 2000 Rwanda 2005 Ethiopia 2005
  71. 71. Exclusive Breastfeeding Under 6 Months Exclusively breastfed 49% Plus plain water only 15% Plus water- based liquids/juice 5% Plus other milk 18% Not breast- feeding 1% Plus comple- mentary foods 14%
  72. 72. Median Duration of Breastfeeding 25.8 2.1 4.4 Any breastfeeding Exclusive breastfeeding Predominant breastfeeding Mediandurationin months
  73. 73. Complementary Foods – EDHS 2005  14% of breastfed children under 6 months are already consuming solid or mushy food.  Only 54% of breastfed children age 6-9 months consume solid or mushy food.
  74. 74. Trends in Children’s Nutritional Status (EDHS 2000-2011) 47 11 52 38 11 47 29 10 44 underweight wasting Stunting percent EDHS 2000 EDHS2005 EDHS 2011
  75. 75. Evolution of child malnutrition in Ethiopia from 1983-2005 (WMS & DHS) 60 64 66 67 55 52 47 47 47 43 47 38 8 8 8 8 9 11 11 1983 1992 1996 1997 1998 2000 2005 Stunting Underweight Wasting
  76. 76. Trends in Child Malnutrition – Urban-Rural difference 0 0 58 55 41 42 30 60 64 67 69 56 53 48 0 0 34 37 30 34 23 0 0 48 48 44 49 40 0 0 6 9 8 6 68 8 8 8 9 11 11 1983 1992 1996 1997 1998 2000 2005 Urban Stunting Rural Stunting Urban Underweight Rural Underweight Urban Wasting Rural wasting
  77. 77. •Child Malnutrition – Comparison with other African countries
  78. 78. 16 18 27 30 45 47 Senegal Egypt Tanzania Kenya* (2003) Rwanda Ethiopia Prevalence of Stunting, DHS 2005
  79. 79. 4 4 5 6 8 11 Egypt Rwanda Tanzania Kenya* (2003) Senegal Ethiopia Prevalence of Wasting, DHS 2005
  80. 80. 6 17 20 20 23 38 Egypt Rwanda Tanzania Kenya* (2003) Senegal Ethiopia Prevalence of Underweight, DHS 2005
  81. 81. key determinants of Growth Faltering in Ethiopia • household resources • parental education • food prices and • maternal nutritional knowledge
  82. 82. • Infant with Low birth weight • Infancy & childhood up to 5 years • Women Chronic energy deficiency - BMI & Height
  83. 83. 23 32 30 19 28 27 20 29 27 Urban Rural Total DHS 2000 DHS 2005 DHS 2011 Percent women BMI <18.5kg/m2, (EDHS 2000- 2011)
  84. 84. Percent Women BMI <18.5 (DHS 2000-2005) 35 42 31 29 48 38 31 39 25 18 27 38 33 27 24 35 33 27 39 21 15 24 0 10 20 30 40 50 60 Tigray Affar Amhara Oromiya Somali B-Gumuz SNNP Gambela Harari Addis… Dire Dawa DHS 2005 DHS 2000
  85. 85. 27 10 10 12 12 0.5 Ethiopia Rwanda Tanzania Senegal Kenya Egypt Percent <18.5 BMI, DHS 2005
  86. 86. Trends in Percentage below 145 cm (EDHS 2000-2011) 4 3 4 3 2 33 3 4 Total Urban Rural DHS 2000 DHS 2005 DHS 2011
  87. 87. Percentage below 145 cm (EDHS 2000-2005) 5 4 4 3 2 3 4 4 2 3 1 3 4 4 2 2 7 4 1 2 2 1 0 2 4 6 8 Tigray Affar Amhara Oromiya Somali B-Gumuz SNNP Gambela Harari Addis… Dire Dawa DHS 2005 DHS 2000
  88. 88. •Factors associated with Poor Maternal Nutrition
  89. 89. Birth intervals - EDHS 2000-2011 8 13 35 24 7 98 11 38 24 19 17-17 18-23 24-35 36-47 48-59 60+ percentage Months since the preceding birth DHS 2000 DHS 2005 DHS 2011 Birth intervals < 24 months in 2011 = 20%
  90. 90. 20 19 19 18 19 1919 19 19 19 19 1919 19 19 19 19 19 25-29 30-34 35-39 40-44 45-49 25-49 Medianageatfirstbirth Current age Median age at first birth, EDHS 2000-2011 DHS 2000 DHS 2005 DHS 2011
  91. 91. •Overweight and Obesity Emerging Nutrition Problem??
  92. 92. Overweight and Obesity in EDHS 2011 5.7 14.9 2.6 4.7 12.1 2.3 1 2.8 0.4 Total Urban Rural Overweight or Obese Overweight Obese
  93. 93. Overweight/obesity trends – EDHS 2005-2011 4 3 0.7 6 5 1 Overweight or Obese Overweight Obese 2005 2011
  94. 94. Overweight and obesity trends in Urban areas – EDHS 2005-2011 14 12 2 15 12 3 Overweight or Obese Overweight Obese Urban 2005 Urban 2011
  95. 95. Overweight and obesity trends in Rural areas – EDHS 2005-2011 2 2 0.3 2.6 2.3 0.4 Overweight or Obese Overweight Obese Rural 2005 Rural 2011
  96. 96. 2 4 2 5 10 2 3 2 10 18 14 3 4 4 5 16 3 6 7 14 20 19 Tigray Affar Amhara Oromiya Somali B-Gumuz SNNP Gambela Harari Addis… Dire Dawa Regional disparities in levels of Overweight or Obesity, EDHS 2005 - 2011 DHS 2011 DHS 2005
  97. 97. Comparison with other countries 4 12 18 22 23 80 Ethiopia Rwanda Tanzania Senegal Kenya Egypt Percent Overweight or Obese, DHS 2005

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