Undernutrition is complex with many causes. Illness depresses the appetite and can affect the absorption of nutrients that the body needs to recover and grow. Beyond this the stats of women, child cares practices, access to water and sanitation , basic health care services and food security all play a role.Based on the UNICEF undernutrition framework (1991) which many of you will be familiar with, showing the multifaceted and complex nature of malnutrition, with many of the causes and solutions, many of which falling outside the health sector. It is estimated that by scaling up the effective 13 nutrition specific interventions as outlined by the 2008 Lancet undernutrition Series) alone (BCC CF, BF ,Hygeine, micronutrients(Vit A,Zn,iron,Iodine etc, TX SAM) stunting could be reduced by 1/3Disease control interventions alone only contribute to 3 % reduction in stunting A similar framework could also be proposed for overnutritionIt is now well established that o reduce stunting alone by the addition 2/3 nutrition sensitive approaches need to be executed at scale and most of these address the underlying and basic causes of malnutrition For example1.Improving EducationA recent study by estimated that women’s education was responsible for almost 43% of the total reduction in undernutrition across 63 counties ( south Asia, Latin America and Africa) between 1970 and 1995 . 2.Gender and empowermentWomen are the primary caregivers and are 43% of the worlds agricultural labour work force, often being the productive members of the household. Women's status is directly related to nutritional outcomes. The same author suggest that improvements in women’s decision making power within the family and society can significantly reduce child malnutrition rates by 12%. This study also suggested that improving the status of women in South Asia would reduce the level of underweight children under three years of age by approximately 12% and in sub Saharan Africa by nearly 3%This is stronger in poorer households than in richTimor and Cambodia DHS all child undernutrition indicators related mothers BMI, education, rural living and socioeconomic status Agriculture75% of the worlds poor live in rural areas of which 86% rely on agriculture to survive. 43 % of the worlds agriculture labour force is womenProvides food, a source of income affects food prices , affects the environment and influences women's time for taling of very young children and their power in decision making.Growth in the agriculture sector and concentrated amongst the rural poor , we see a faster reduction in stunting. The relationship is even stronger in food insecure populations. A systematic review by DFID revealed that agricultural interventions improve the production and consumption of nutritious food among poor households but could not identify a direct impact on the nutritional status of children ( studies too small)Social protectionCC T- Mixed results. UCTs in Mexico, Nicaragua and Colombia have shown some evidence of effect of unconditional transfers in South Africa. Some evidence that when pregnant women and children under 5 are prioritised for CCTs, and good communication to beneficiaries takes place… they can be more successful ( egg program in Brazil mothers thought they would excluded if they grew normally)WASHPoor evidence for nutrition in this area. Some evidence between sanitation and stunting. One multi country study showed that improved sanitation is associated with a reduction in height deficit, ranging from 22 – 53% for urban children and from 4-37% for rural children. For water supply the effects were smaller.Hygiene interventions ( including hand washing with soap, water treatment, sanitation and health education) have been estimated to Family planningAge of first pregnancy and impact on LBWBirth spacing Total fertility rateSocioeconomic status A study from 1985Baxter and Water low (1985)4All high-income children in all countries are approximately the same height and all are approximately at 0 z-scores - the average height of the international growth reference.All low-income children in all countries are significantly shorter (by up to 12 cm) than high-income children and have average height z-scores well below zeroIn many countries, dramatic seasonal differences in the availability of foods and incidence of infectious disease have significant effects on growth.
The damage that occurs from undernutrition in a child’s first 1,000 days, from pregnancy to 24 months of age, is largely irreversible. During this period, nutritional requirements are substantial, in terms of caloric and micronutrient needs for both pregnant women and young children given the rapid growth and development that takes place. As shown in Figure A-6, stunting and underweight can begin in utero, where children who have not received adequate nutrition during gestation are born with a negative z-score for either weight-for-age or height-for-age. Growth faltering occurs mainly before a child’s second birthday, when children are particularly vulnerable to poor caring behaviours, inadequate access to health services, and inappropriate feeding practices, all of which can have detrimental consequences for their health and survival.Therefore, this critical period or “window of opportunity” between pregnancy and 24 months is when undernutrition can and should be prevented. Timing of growth retardationIn poor environmental conditions, deviations from normal growth start at a very young age. The fastest period of growth is in the first 2 years of life, and it is not surprising that poor dietary intake and high incidence of infection in early childhood have significant negative impacts on child growth. At birth, the percentage of underweight, wasted and stunted children is low.Shortly after birth, the percentage of stunted (low height-for-age) and underweight (low weight-for-age) children in this population rise dramatically. By 2 years of age (24 months) >50% of children are stunted and this does not improve before the end of the data shown in the figure at 5 years of age (59 months). This clearly shows that the process of stunting occurs in early childhood (before 24 months of age) and results in short children with no sign of catch-up in height before age 5 years.The percentage of children who are wasted (low weight-for-height) in this population rises to about 25% at around 8/9 months of age but slowly decreases to below 10% by 24 months of age.The findings from these data have been supported by child growth data drawn from the WHO global database on Child Growth and Malnutrition, largely drawn from low- and middle-income countries. They suggest that by 5 years of age, children are short relative to international reference population but have normal weight for their height.
General.Low birth weight <2.5kg) arises through short gestation (preterm birth) or in-utero growth restriction, or both. 20 million babies (14 % of children born) are estimated to be born with low birthweights every year—half in south Asia. Neonatal deathsIntero-utero restriction in term neonates - Direct cause of 1-2 % of neonatal deathsIndirect cause of 60-80% of neonatal deaths particularly those deaths due to birth asphyxia and infections ( sepsis, pneumonia and diarrhoea)28% of neonatal deaths globally are directly attributable to preterm birth Delayed learningPoor fetal growth or stunting in the first 2 years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income, and decreased off spring birthweight Chronic disease• There is no evidence that rapid weight or length gain in the first 2 years of life increases the risk of chronic disease, even in children with poor fetal growth however. children who are undernourished in the first 2 years of life and who put on weight rapidly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition
More women enter pregnancy with a body mass index >30 kg/m2, leading to an increased risk of complications during pregnancy and delivery. Their infants tend to be born larger and are at greater risk of becoming obese and developing type 2 diabetes as children and adolescents. These women also tend to retain more weight after birth. In response to the high plasma glucose levels in mother, the foetus has high circulating blood insulin and becomes a big baby placing them at risk of obesity and NIDDM later in lifeIt is apparent from studies of the developmental origins of disease that there is a strong intergenerational component to health. TMaternal overweight and obesity in pregnancy influence disease risk among offspring. For example , gestational diabetes is related to offspring body composition and increased risk of insulin resistance and diabetes in offspring. There is concern about an intergenerational amplification of diabetes risk.Women who were malnourished as children are at increases risk of being centrally obese and having impaired glucose tolerance as adults. If these conditions affect a women's pregnancy her offspring will be at increased risk of early development of obesity and diabetes. As obesity develops at younger and younger ages, the likelihood that adolescents and young women who become pregnant will experience complications associated with gestational diabetes is a risk factor for child obesity through a pathway related to fetal overnutrition.On the other end of the spectrum short maternal stature acts as a physical constraints on fetal growth and stunting in offspring may in turn relate to increases obesity risks
As countries have industrialised/ urbanisation More edible oils eaten , less exercise, more sedentary work, less time allocated to active recreation.Occurring in all countries.Occurring within households and within groups
Timor ..slow results in addressing under nutrition Although overnutrition is a newly emerging issue, it is emergingTimor 2003 – 0.3 % in children under 5, in 2010 0.7% with some provinces districts experiencing rates of 11%Non pregnant women it is 5.1 %/ girls 15-19 1.5 % and growing Brazil storyOn the basis of 3 comparable population-based surveys conducted in Brazil ( 1975, 1989,1997 ) trends in over and undernutrition in women were examined. Between this period undeweight nearly halved and obesity nearly doubled1975, there were almost 2 cases of underweight to 1 case of obesity (mostly in high socioeconomic groups),1997, there were more than 2 cases of obesity to 1 case ofunderweight. In 1997, Brazilian low income women were significantly more susceptible than high-incomewomen to both underweight andobesity.
2000 The Millennium Development Goals: Nutrition has a direct and or indirect role in achieving all 8 goals. 1, 4 and 5 being the most direct The Lancet Series on Maternal and Child Undernutrition : The first 2 papers identify the 36 “high burden” countries in which 90% of the world’s stunted children live, assess the consequences of undernutrition on disease burden and mortality and examine the long-term educational and economic consequences of the double burden of malnutrition. The third paper estimates the effectiveness of the 44 nutrition specific and nutrition sensitive interventions . The final two papers consider the current status of effective interventions and how these could be scaled up. The 36 high burden countries are:Afghanistan, Angola, Bangladesh, Burkina Faso, Burundi, Cambodia, Cameroon, Côte d'Ivoire, Democratic Republic of the Congo, Egypt, Ethiopia, Ghana, Guatemala, India, Indonesia, Iraq, Kenya, Madagascar, Malawi, Mali, Mozambique, Myanmar, Niger, Nigeria, Nepal, Pakistan, Peru, Philippines, South Africa, Sudan, United Republic of Tanzania, Uganda, Viet Nam, Yemen, Turkey, Zambia. 3. REACH Ending Child Hunger and Undernutirtion Partnership: Established in 2008 by WFP, UNICEF, FAO and WHO. REACH promotes a country-led approach to scale-up proven interventions to address child undernutrition through the coordinated action of UN agencies, civil society, donors and the private sector, under the leadership of national governments4. 2008 Copenhagen Consensus: a project that establishes priorities for advancing global welfare using methodologies based on the theory of welfare economics. The 2008 conference report identified supplementing children with zinc and vitamin A as the worlds’ best development investment. 2012 Copenhagen Consensus: conference report ranked investing in bundled micronutrient interventions to fight hunger and improve education as the most desirable of the 16 interventions proposed5.The WHO Landscape Analysis of readiness to accelerate action in nutrition: a systematic approach to assessing where to invest and how to best invest to accelerate action in nutrition. Landscape analyses have been conducted in Timor, Sri Lanka and Indonesia . All others have been conducted in Africa and peru6. Scaling up Nutrition: What will it cost? A report that estimates the cost of scaling up a minimal package of 13 proven nutrition interventions from current coverage levels to full coverage of target populations in the 36 countries with the highest burden of stunting (90% of all stunted children) and 22 smaller countries with prevalence's of undernutrition above 20%.7. The Scaling Up Nutrition (SUN) movement was launched in 2010. SUN is a global movement that brings organizations together across sectors to support country led multisector national plans to scale up nutrition by helping to ensure that financial and technical resources are accessible, coordinated, predictable and ready to go to scale 35 countries (Bangladesh,Benin,Burkina Faso,Burundi,Cameroon,Elsalvador,Ethiopia,Gambia,Ghana,Guatemala,Haiti,Indonesia,Kenya,Kyrgyz Republic,Lao PDR,madagascar,Malawi,Malii,Mauritani,Mozambique,Namibi,Nepal,Niger,Nigeria,PPakistanPerù,Rwanda,Senegal,Sierra Leone,Sri Lanka,Tanzania,Uganda,YemennZambia,Zimbabwe8.The 1,000 Days Partnership promotes targeted action and investment to improve nutrition for mothers and children in the 1,000 days between a woman's pregnancy and her child's 2nd birthday9. The WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition (2012-2025) was endorsed by the World Health Assembly , Resolution 65.6 and urges all members to support the implementation of the 6 Global Targets2012 – 2025 (13 years)Target 1 - 40% reduction of the global number of children under 5 who are stuntedTarget 2- 50% reduction of anemia in women of reproductive ageTarget 3 - 30% reduction of low birth weightTarget 4 - Increase exclusive breastfeeding rates in the first 6 months up to at least 50%Target 5 - No increase in childhood overweightTarget 6 - Reducing and maintaining childhood wasting to less than 5%9.New Lancet Series on child and maternal nutrition. Launch is June6. This series will comprise 4 papers, and is set to analyse, among other things: (a) what has been learned in and from the past 5 years, (b) what has changed in the external environment, (c) what are the set of challenges that different actors need to focus on in the next 5 years, and (d) how to lock in the commitment to nutrition for the medium term.The series will retain the focus on undernutrition, but will give more attention to obesity and healthy diets. It will also focus more on the indirect or potentially nutrition sensitive policies and programmes in areas such as food and agriculture, social protection, women’s empowerment, water and sanitation, and early childhood development/education. The series will have more of a political economy focus, with paper 4 (the one I am working on) focusing on what an enabling environment for nutrition looks like and how it can be created and sustained
Asia With the exception of a few countries nutrition transitionMyanmarPacificDouble burden More focus on over weight and NCDOut of date data and plansIssues of undernutrition requiring more attention POLICY BRIEF
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Nutrition – the emerging issuesHeather Grieve- Nutrition Team Leader, Womensand Childrens Health Knowledge Hub
Inadequate food intake DiseaseHealth careFood security Water security Hygiene & sanitationFamily planningGender equityTransport Infrastructure Social protectionClimate EducationIncome & employmentGovernance SecurityTradeImmediatecausesUnderlyingcausesBasiccausesSource: Adapted from UNICEF 1991Conceptual framework for the causes of undernutritionCaring practices
Undernutrition - The immediate effectsRepeated infections,persistent undernutritionDiseaseUndernutritionIncreased durationand severity ofillnessIncreased nutrientrequirementsIntestinal damageMalabsorption and/ orloss of nutrientsSystemic infections, e.g.malaria, pneumonia,measlesFever and illnessIncreased nutrientrequirementsDiarrhoea & other gutinfections
Frequent infectionsLow birth weightand or pre-termbabyStunted childStuntedadolescentSmall pregnantwomanImpaired mental developmentInadequate growthReduced mentalcapacityReduced mental capacityBirth complicationsMaternal mortalityIntra-uterine growth restrictionGreater risk of developingchronic disease such as heartdisease, hypertension anddiabetesUndernutrition - The long term effects
Macrosomia( birth weight >4000g)Overweight/obeseadolescentOverweight /obesepregnant womanGreater risk of developing chronicdisease such as non-insulindependent diabetesPregnancycomplications (e.g.preeclampsia andgestational diabetes)Birth complicationsOverweight/obese childGreater risk of developing chronicdisease such as non-insulindiabetesOvernutrition -The long term effects
40%22%16%9%6%42%17%47%41%12%6%14%7%13%6%17%9% 10%Indonesia Vietnam Mongolia China Tuvalu Pakistan Kazakhstan Malawi NigeriaStunting OverweightPrevalence of stunting (HAZ < -2) and overweight (WHZ > 2) in children underfive years by countryThe double burdenSource: Country demographic and health surveys; World Bank Data; UNICEF State of theWorld’s Children report; WHO data tables
The nutrition transitionTrends in nutritional status among women aged 15 – 49 years, CambodiaSource: Cambodia DHS 2010
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013The nutrition landscape in the 21st CenturyUnderJune 6 2013 New SeriesMaternal and ChildNutrition with greaterattention to the doubleburden, the role of othersectors and the enablingenvironment required toscale up nutritionSeries on Maternal andChild UndernutritionWHA endorsed CIPmaternal, infant andyoung child nutrition(6 global targets2025)WHO The Landscape Analysisin-depth Country Assessments
Scaling up nutrition, what are countries being asked to do?MobiliseresourcesScale upnutritionspecificinterventionsAddress thedouble burdenAlign andcoordinateactionsacrosssectors
Asia Pacific - regional profileAsia• High prevalence ofundernutrition (stuntingand micronutrientdeficiencies)• ‘Nutrition transition’• More current nutritionplans with a focusmostly on underweightPacific• ‘Double burden ( highrates ofoverweight/obesity, stunting and micronutrientdeficiencies)• Nutrition plan mostly outdated or directedtowards overweight andobesity
Source: Timor Leste DHS 2010; WHO Micronutrient Data Base, UNDP Human Development IndexTimor LesteChildren < 5 years• IMR: 64/1000 livebirths• Wasting: 19%• Stunting: 58%• Underweight: 45%• Anaemia : 38%• Vit A deficiency:48.5%• Overweight: 0.7%Non- pregnant women• Underweight :27%• Short stature: 15%• Overweight: 5%• Anaemia :21%Pregnant women• TFR: 5.7• Anaemia :28%• MMR: 557/100,000live births• Vitamin A deficiency:2%• 8/10 women birth athome• Median age of firstbirth: 22.4 yearsNutrition capacity• No pre-service and limited in-service nutrition training• New nutrition assistantpositions in some districtsNational nutrition plansand policies• Comoro Declaration• National NutritionStrategy (2013-2018)waiting endorsement• National NutritionSurvey 2013Food security• 60% of thepopulation live on< US$1/day• 40% live belowthe poverty line(55c/day)• 20% of thepopulation arefood insecure• 44% are at risk offood insecurityEducationMean years ofschooling (adults):4.4 yearsPopulation: 1.12 million
Source: PNG National Nutrition Survey 2005;UNDP Human Development Index ;State of the Worlds Midwifery 2011Children < 5 years• IMR: 69/1000 livebirths• Wasting: 5%• Stunting: 43%• Underweight: 18%• Anaemia : 48%• Vit A deficiency: ?• Overweight : no dataNon- pregnant women• Underweight : nodata• Short stature: no data• Overweight: 46%• Anaemia: 36%Pregnant women• TFR: 4.1• Anaemia : 55%• MMR: 250-530/100,000 live births• Adolescent birth rate(births/1000 womenaged 15-19):70• Median age of firstbirth:20.5 yearsNutrition capacity• No pre-service and limited in-service nutrition training• Four nutrition staff at centrallevel and very limited nutritionstaff in the 22 provincesNational nutrition plansand policies• National NutritionPolicy (1995)• IYCF Strategy (draft)Food security• 36% of thepopulation live on< US1.25/day• 28% live belowthe poverty line(% of populationfood insecure: nodata• % of populationrisk of foodinsecurity: no dataEducation• 40% of women(15-49 yrs.)haveno education• Average years ofschooling :3.9years• Female literacyrates : 56%Population: 6.5 millionPapua New Guinea
Nutrition capacity development -The Nutrition Critical Appraisal Tool• Stakeholder consultations in 2009/10 supported the 2008 Lancet Series onMaternal and Child Undernutrition indicating a need to:o build capacity of governments to prioritise and plan nutritionprograms effectivelyo move away from vertical programming and scale up nutrition programsusing integrated approaches based on best practice• The format is based on 1000 days ‘window of opportunity’ from preconception (including adolescents ) to two years of age• The content is based on:o Interventions outlined in the 2008 Lancet Series on Maternal and ChildUndernutritiono WHO Evidence of Nutrition Actions (eLENA)o Globally endorsed nutrition frameworks, policies and procedureso Principles of the Scaling Up Nutrition (SUN) strategy 2012-2015o Best practice case studies from the region• Guides users through current evidence and best practice, and provide links tokey documents, resources and relevant case studies.• Currently being pre-tested
Nutrition capacity development- The Nutrition Critical Appraisal Tool
Nutrition capacity development- Nutrition and Food Security-Approaches to improving the health of women and children short course• Evidence about the ‘what and how’ for nutrition is rapidly changing• Lack of relevant comprehensive in-service training that covers;o nutrition across the 1000 days lifecycleo under and over nutritiono the role of nutrition specific and the nutrition sensitive approaches innutrition programming• Nutrition and Food Security- Approaches to improving the health of womenand children short course developed Nutrition planning and programming Nutrition for infants and young children Nutrition for adolescent girls and women of reproductive age Food security for families and communities• Each module uses local data and where possible local case studies asexamples• 2012/13 adapting the course for district and sub district health and agriculturalextension workers in Timor Leste
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