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Lancet Series Update 2013

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Lancet Series Update 2013. By Monica Muti National Nutrition Technical Update Meeting 05-06 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 paper. - PowerPoint PPT Presentation
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Lancet Series Update 2013 By Monica Muti National Nutrition Technical Update Meeting 05-06 August 2013 Kadoma Hotel
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Page 1: Lancet Series Update 2013

Lancet Series Update 2013 By Monica Muti

National Nutrition Technical Update Meeting05-06 August 2013

Kadoma Hotel

Page 2: Lancet Series Update 2013

Maternal and Child Nutrition 1:

Maternal and child undernutrition and

overweight in low-income and middle-income countries

Page 3: Lancet Series Update 2013

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

Page 4: Lancet Series Update 2013

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.

Page 5: Lancet Series Update 2013

Framework for action to achieve optimum fetal and child nutrition and development

Page 6: Lancet Series Update 2013

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

Page 7: Lancet Series Update 2013

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)

Page 8: Lancet Series Update 2013

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

Page 9: Lancet Series Update 2013

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

Page 10: Lancet Series Update 2013

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

Page 11: Lancet Series Update 2013

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

Page 12: Lancet Series Update 2013

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

Page 13: Lancet Series Update 2013

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.

Page 14: Lancet Series Update 2013

Maternal and Child Nutrition 2

Evidence-based interventions for improvement of maternal and child nutrition: what can

be done and at what cost?

Page 15: Lancet Series Update 2013

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

Page 16: Lancet Series Update 2013

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

Page 17: Lancet Series Update 2013

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

Page 18: Lancet Series Update 2013

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

Page 19: Lancet Series Update 2013

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%

Page 20: Lancet Series Update 2013

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

Page 21: Lancet Series Update 2013

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

Page 22: Lancet Series Update 2013

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

Page 23: Lancet Series Update 2013

Disease prevention and managementInpatient treatment for children with

complicated SAMCommunity-based care for uncomplicated

SAMprogrammatic evidence supports use of RUTF

for community-based treatment

Page 24: Lancet Series Update 2013

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


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