nutrition in children mch in developing countries hserv/gh 544

HSERV 544 - Nutrition in Children 1

Nutrition in ChildrenMCH in Developing Countries HSERV/GH 544

Jonathan GorsteinClinical Associate ProfessorDepartment of Global Health


Terminology

• Hunger – physiological state when food not able to meet energy needs

• Malnutrition – impaired development linked to both deficient and excessive nutrient intake

• Undernutrition – most common form of malnutrition in developing countries; energy, protein and micronutrients


Major Nutritional Problems in the World

• Protein-energy malnutrition• Obesity• Micronutrient deficiency problems

– Iron deficiency anemia– Vitamin A deficiency– Iodine deficiency disorders– Zinc deficiency– Folate deficiency

• Nutrition-related chronic diseases


Causes of Undernutrition

• Undernutrition is a complex condition that involves multiple, overlapping deficiencies of protein, energy and micronutrients – rarely do these occur in isolation

• The primary cause of undernutrition is an inadequate food intake, but is compounded by illness and malabsorption

• Insufficient access to food, poor health services, the lack of safe water and sanitation, inadequate child and maternal care and poverty are underlying causes

5

• (UN

Lancet 2008: Causal pathways in undernutrition

HSERV 544 - Nutrition in Children


Classification of Malnutrition

• WHO recommends three anthropometric indicators for assessment of nutritional status– Wasting (Low weight-for-height)– Stunting (Low height-for-age)– Underweight (Low weight-for-age)

• Classification based on International Growth Reference

Source: UNICEF Global Database, Nov 2009Compiled from MICS, DHS and other national surveys

Chronic Undernutrition - 195 Million under-fives in the developing world are stunted - 80% of them live in just 24 countries



Intergenerational Cycle of Undernutrition

The cycle of poor nutrition perpetuates itself across generations - supported by scientific evidence

Childhood: Child growth failure, impaired mental

development

Adolescents: Low weight and height

Pregnancy Compromised

nutritional status

Adult: Small adult woman, lowered

productivity

Fetal and Infant stages: Low

birthweight baby

Impact of Undernutrition

• Increased risk of dying from infectious diseases • Stunting is associated with reduced school

performance and lower income earning capacity (22% average; up to 45% has been reported!)

• Increased risk of non-communicable diseases in adult life

• Reduced GNP by 2-3%• About 20 million children suffer from severe acute

malnutrition which greatly increases risk of death



Infection-Malnutrition Synergism

Weight lossGrowth faltering

Immunity lowered

Appetite lossNutrient loss

MalabsorptionAltered Metabolism

Inadequate dietary intake

Disease IncidenceSeverityDuration


Causes of Mortality among Preschool Children, 2005

23%

18%

15%

10%

5%

25%

4%

Source: WHO (2003)

Deaths associated with undernutrition

55%

Other

HIV/AIDS

Measles

MalariaDiarrhea

Acute Respiratory

Infection

Perinatal


Micronutrients

• Micronutrients are needed by the body only in minute amounts, are critical for:– Regulation of growth, activity, development – Immune and reproductive function

• Three primary micronutrient deficiencies include:– Iodine– Vitamin A– Iron


0.0

0.5

1.0

1.5

2.0

2.5

Iodine Iron Vitamin A

People(billions)

1.6

2.0

0.8

Population at Risk of Deficiency - Global

Source: UNICEF (2002)


Iodine Deficiency Disorders (IDD)

• Single most important cause of preventable brain damage and mental retardation

• Significantly raises the risk of stillbirth and miscarriage in pregnant women

• About 50 million people worldwide suffer from varying degrees of brain damage and physical impairment due to iodine deficiency – Concept of IDD (Spectrum of disability)

• The primary intervention for the control of IDD is through salt iodization


Today• Some 70 per cent of households in

the developing world are using iodized salt, compared to less than 20 per cent at the beginning of the decade.

• As a result, 91 million newborns are protected yearly from significant loss in learning ability

Iodine Deficiency Disorders (IDD)

Unfinished Business• There are still 35 countries where less than half the households

consume iodized salt


Vitamin A Deficiency

• Contributing factor in 2.2 million deaths each year from diarrhea and 1 million deaths from measles among preschool children under five

• Severe deficiency can also cause irreversible corneal damage, leading to partial or total blindness

• Results of field trials indicate that VA supplementation of children with can reduce deaths from diarrhea. Four studies showed deaths were reduced by 35-50 per cent.

• VA can reduce by half the number of deaths due to measles


Magnitude of Vitamin A Deficiency

• Pre-school children• Clinically deficient: 3 million (Asia and Africa)• Subclinically deficient (low serum retinol): 100-140 million• 250,000-500,000 become blind each year• 90 % case fatality among those who become blind

• Pregnant women• 25%-30% cases of night blindness reported in some Asian

countries


Interventions to Control VAD

• In 1999, only 10 countries provided two rounds of VA supplementation with high coverage, this has increased to over 50 countries by 2004.

• Between 1998 and 2004, UNICEF estimates that about two million child deaths may have been prevented from vitamin A supplementation

• Food Fortification - A number of countries are successfully fortifying staple foods with vitamin A (e.g. sugar, maize flour, wheat) reaching large populations.


Iron Deficiency and Anaemia

• Most common nutritional disorder in the world• Lowers resistance to disease and weakens a child's

learning ability and physical stamina • Significant cause of maternal mortality, increasing the

risk of hemorrhage and infection during childbirth.• Nearly 2 billion people estimated to be anemic and

millions more are iron deficient, the vast majority are women.

• Supplementation and fortification are primary interventions to improve iron intake


Global Prevalence of Anaemia:Pregnant Women

01020304050607080

Africa

Americas

South-East

Asia

Europe

Eastern

Mediterranean

Western

Pacific

Source: WHO (1999)


Main Factors Contributing to Anaemia

• Iron deficiency– Poor bioavailability of consumed iron– Insufficient dietary iron intake

• Chronic and recurrent infections that interfere with food intake and absorption/utilization of iron– Helminth infections, primarily Hookworm– Chronic diarrheal disease– HIV– Malaria


Interventions to Control Anaemia

• Depends on etiology– For iron deficiency: supplementation and

fortification– For parasitic disease control: appropriate

measures for prevention and presumptive treatment

“Nutrition-sensitive programming” -- moving from a narrow “nutrition lens” to a wider “development lens”

Financing envelope

Health sector

Narrow nutrition lens

Multi-sectoral nutrition lens

Education sector

Agriculture sector

Private sector

Financial and credit sector

Trade and tax policies sector

Social welfare sector

Multiple other sectors


Multi-sectoral programs - Priority intervention areas

Interventions are proven and known to be effective. The challenge is to scale them up

Improve breastfeeding and complementary feeding

Improve hygiene and parasite control

Hand washing with soap

Household water treatment

Bed nets and intermittent preventive treatmentDeworming

Exclusive breastfeeding Complementary feeding

Improve availability and diversity of food and support livelihoods

Increase treatment of severe acute malnutrition

Food security

HealthNutrition

Care

Increase micronutrient intake

Strengthening smallholder farmers

Local food production

Transfers and safety nets

Treatment SAM

Micronutrient supplementation and fortification

Supplementary feeding

Home Fortification: Reaching Target Groups

• Objective: Provide additional vitamins and minerals to a diet based exclusively on cereals

• Challenge: Identifying and reaching those in need• Access: Where do caregivers access products and health services• Considerations for free distribution• Examples of distribution models

a. Free of charge to consumers (public distribution)b. Subsidized to consumers (market based)c. Consumers pay full price (market based)


Types of delivery channels for Sprinkles

Public distribution• Free of charge

to beneficiaries through clinics and public distribution channels

Consumer purchasing

• Beneficiaries purchase and bear full cost of product

Hybrid

Subsidized Support to•Production•Storage•Social marketing•Vouchers•Conditional cash transfers


Example of Hypbrid Model: Renata-BRAC Pushtikona

Model type: subsidized & consumers pay full price• Renata (pharmaceutical) + BRAC (NGO)• MNPs sold through Renata pharmacies and usual distribution as well

as BRAC Shasthya Shebitka female sales persons• In Bangladesh, MNPs are registered as a pharmaceutical

– Possible to market


Strengths of Model: Renata-BRAC

• BRAC is biggest NGO in the world– Guaranteed demand leads to decreased costs

• BRAC distribution network is extensive and national• Income generation for women• Builds off Danone-Grameen Project (Fortified yougurt)



Thank you

nutrition in children mch in developing countries hserv/gh 544

Documents

ageunderweight low weight

developing countries

low birthweight babyhserv

heightstunting low height

nutritional statusadult

developing countries

inadequate child

inadequate food intake