Public Nutrition:
Policies and Programs
INHL 613
Tues – Thurs 3.00 – 4.40
12 Jan – 2 Mar 2010
Course.
1. Principles and introduction
2. Community-based Health and Nutrition Programs
3. Micronutrient Programs
4. National planning exercise.
1. What are nutrition and public nutrition?
2. Consequences of malnutrition (hence: why bother?)
3. Causes of malnutrition to tackle (what to do about it?)
4. Brief epidemiology
5. Context and program principles
Introduction
TABLE 23. Estimated reductions in the disease burden (% DALYs lost) in developing countries (all population groups, all causes), from children underweight or deficiencies of vitamin A (clinical), iodine (measured as goiter), and anemia; from the direct effect (the deficiency considered as a disease itself) and as a risk factor for other diseases (infectious diseases only included in estimating reduction).
Note: underweight refers to children 0-59 months, < - 2 SDs weight-for-age; vitamin A deficiency is calculated from clinical deficiency in children 0-59 months; anemia refers to women 15-49 years; IDDs refers to iodine deficiency disorders, all ages, calculated from goiter prevalences. Methods are given in the source. Source: Mason, Musgrove & Habicht, (2003), table 10: [39]
Direct effect As risk factor Total Child underweight 1.0% 14.0% 15.0% Vitamin A deficiency 1.0% 4.5% 5.5% Anemia 3.3% 0.3% 3.6% IDDs 4.7% 3.7% 8.4% Total 10.0% 22.5% 32.5%
What does ‘nutrition’ cover? Consequences …
For children:•Health (direct and risk factor – see DALYs)•Survival/mortality risk•Intellectual development, educational result•Nutritional status (micronutrients, growth – affects future earnings)
For women:•Health (direct and risk)•Reproduction, intra-uterine development in pregnancy•Nutritional status (especially anemia)
For all:•Health•Activity, productive and discretionary•Freedom from hunger
These apply to undernutrition and obesity: we deal mainly with undernutrition.
"PUBLIC NUTRITION
includes the following activities:
an understanding and a raising of awareness of the nature, causes and consequences of nutrition problems in society;
epidemiology, including monitoring, surveillance, and evaluation;
nutritional requirements and dietary guidelines for populations;
programs and interventions: their design, planning,
management, and evaluation;
community nutrition and community based programs;
public education, especially nutrition education for behavioral change;
timely warning and prevention and mitigation of emergencies, including use of emergency food aid;
advocacy and linkage with, for example, population and
environmental concerns;
public policies relevant to nutrition in several sectors, for example, economic development, health, agriculture, and education.”
Source: letter to Am J Clin Nutr, March 1996,63399-400, Mason, Habicht, Greaves, Jonsson,
Kevany, Martorell, and Rogers.
‘Public
Nutrition…’
Mortality risk
J Nutr.124:2106S-2122S, 1994
Source: Lancet nutrition series #1, 2008
15-20 years later
Maternal and child undernutrition: consequences for adult health and human capital
Source: Lancet nutrition series #2, 2008
Source: 2nd and 6th UN World Nutrition Report/Tulane.
DRAFT
Nutrient Size (req/day) Role, reason Deficiencies
1. CHOs, Fats, N(protein: AAs)
Up to 500 g Energy, buildingblocks – structure,metabolism
Diverse clin signs. Not clearly linked torole.
2. Na, K, Ca. Up to 5 g Solute (seawater),homeostasis
Not really seen
3. Phosphate, Cl Up to 5 g As 2 Not really seen
4. Vit C Up to 0.1 g, 100mg
Antioxidant in mostcells; enzyme lostin evolution
Scurvy. Not clearlyrelated to function.
5. B-vits Up to 50 mg Co-factors inmetabolism(opportunisticevolution)
Specific signs, notclearly related tofunction
6. Essential Aasand FAs
... g Structure,metabolism; like B-vits
Some specificsigns, but not wellknown nor clearlyrelated to function
7. Metals: Fe, Zn,Cu, Mg, Mn, ...
1 – 10 mg(available)
a) Fe: carry O2
b) active sites ofenzymes (incl. Fe)c) other (e.g.cognitive)
a) anemia andcorrelatesb) non-specific orno signs (e.g. Zn)c) research area
8. I, vit D mcg Hormones, controlof homeostasis,growth, etc.
Specific signs(IDDs, rickets)when severe.
9. Vit A mcg a) visual cycleb) membranes
Specific signswhen severe; mild,mortality effect
plus almost all affect immune system
‘Nutrition…’
What does ‘nutrition’ cover? Causes and interventions.
See various frameworks, e.g. UNICEF – proximal causes:•Poverty and food security•Health environment, access to services•Care …
(Converse of hunger, sickness, and neglect)These interact and have important feedback loops (e.g. see malnutrition-infection spiral). More distal causes often are contextual rather than intervenable upon.
Time and biology are crucial – intra-uterine development (even at conception) has major influence (even on next generation).
Context, and program interventions: context determines whether interventions are effective; often cannot be quickly changed.
Single interventions are of well-known effectiveness, but they also importantly interact and have feedback loops. Issues are HOW to sustainably support them, and combine them.
Inadequatedietary intake Disease
Malnutrition and death
Inadequateaccess to food
Inadequate carefor mothers andchildren
Insufficient healthservices and un-healthy environ-
ment
I na d e q u a t e e d u c a t i o n
Potentialresources
Political and ideological superstructure
Economic structure
Formal and non-formal institutions
Outcomes
Immediatecauses
Underlyingcauses
Basiccauses
Source: Redrawn from UNICEF, 1990 [39]
Figure 1.8. Conceptual framework for the causes of malnutritionin society
Inadequate dietary intake
Weight loss Growth faltering Immunity lowered
Mucosal damage
Disease: - incidence - severity - duration
Appetite loss Nutrient loss Malabsorption Altered metabolism
Malnutrition-infection cycle
Normal weight
Infection
Mild underweight
Worse Infection
Worse Infection
Severe or Fatal Infection
Moderate underweight
Severe underweight
Spiral of malnutrition and infection
Better nutrition
Time
Source: Lancet nutrition series #3, 2008
Epidemiology
Source: Lancet nutrition series #1, 2008
0 20 40 60
Underweight
Anemia
VAD
IDD
Figure 13. Summary of estimated regional prevalences of underweight, anemia, vitamin A deficiency (sub-clinical), and IDDs, in pre-school children, c.1995 (see table 8 for data)
Table 8Illustrative Table of Prevalences of Nutritional Problems and Implied Overlap of Deficiencies in Preschool Children
RegionUnderweight
(1995)Anemia
(1975-97)Vitamin A Deficiency
(sub-clinical)1995
IDD Affected1985-1996
With 2 or more NutritionalDeficiencies
Prev-alence
Est. No.affected(millions)
Prev-alence
Est. No.Affected(millions)
Prev-alence
Est. No.Affected(millions)
Prev-alence
Est. No.Affected(millions)
PrevalenceEst. No.Affected(millions)
South Asia 52% 87.4 52.7% 93.8 35.6% 59.5 25.3% 42.5 27.4 C 35.6% 46.1 C 59.8
Sub-Saharan Africa 30% 30.9 33.1% 34.1 35.3% 36.0 29.2% 30.1 11.7 C 35.2 % 12.1 C 36.3
Middle East/ North Africa 16% 7.4 38.3% 17.7 9.8% 4.2 24.0% 11.1 9.2 C 24.0 % 4.3 C 7.4
East Asia / Pacific 23% 39.3 14.1% 20.0 18.2% 29.6 18.2% 31.1 4.2 C 18.2 % 8.2 C 31.1
Latin America/Caribbean 11% 6.2 22.9% 13.0 19.6% 10.2 15.6% 8.8 4.5 C 19.6 % 2.5 C 11.1
TOTAL 31% 171 35 % 190 26 % 140 23 % 124 13 C 27% 73 C 146
Context
C o n t r ib u t io n s t o r e d u c in g u n d e r w e ig h t .
- 1
- 0 . 5
0
0 . 5
1
1 . 5
2
2 . 5
3
3 . 5
T h a i I n d ia C a m e r o o nChan
ge in
uwt
pre
v, pp
ts/y
r
B a s eG D PL itH l t hE x p la in e dR e s F in a l
M o d e l: c h a n g e in u n d e r w e ig h t = 0 .4 5 3 – 0 .1 0 2 ( G D P g r o w th , % / y r ) – 0 .0 0 9 2 ( w o m e n ’s l i t e r a c y le v e l, % , a v e o f 1 9 8 0 /9 5 ) – 0 .0 4 8 ( m e a s le s im m u n iz a t io n , c h a n g e b e tw e e n s u r v e y s , p e r c e n t a g e p o in t s / y r ) . N = 6 1 , a d j R s q u = 0 .2 2 7 , p = v a lu e s f o r c o e f f ic ie n t s : G D P = 0 . 0 0 3 , l i t e r a c y = 0 .0 1 6 , m e a s le s = 0 .0 6 4 . C o n t r ib u t io n s c a lc u la te d a s c o e f f ic ie n t s * v a lu e s f o r e a c h c o u n t r y . B a s e = c o n s ta n t . E x p la in e d = s u m o f c o e f f ic ie n t s * c o u n t r y v a lu e s . R e s id u a l = a c t u a l – p r e d ic t e d . F in a l = a c tu a l c h a n g e o b s e r v e d ( = e x p la in e d + r e s id u a l) .
Context Rights
Program Intervention
Livelihood Health Nutrition
Worse Better
Source: based on slide by F Henry, CFNI.
Program Intervention and Context
A. In unfavourable context, program intervention for the individual has limited effect
Context Rights
Program Intervention
Livelihood Health Nutrition
Worse Better
Source: adapted from Figure 2A
Program Intervention and Context
B. In better context, program intervention for the individual has much more effect
Context Rights
Program Intervention
Livelihood Health Nutrition
Worse Better
Source: adapted from Figure 2A
Program Intervention and Context
C. In highly supportive context, improvement is endogenous and program intervention gives additional effect
Contextual Success Factorshpn/n2 -14
These apply to local programs overall, not to specific components -- eithermost appropriate activities can work, or not, depending on context.
If you cannot change critical context factors, you may have to targetelsewhere. There is no point in having a program which produces no effect(especially for predictable reasons).
Can you change the context, by policy and/or advocacy?
Factor Change it?
1. Political commitment Usually difficult in short-term
2. Women’s involvement indecisions
Usually difficult in short-term
3. Community organizations --CRUCIAL!
Essential; if do not exist must bebrought about and supported
4. Literacy, esp. women’s Can support for long-term change
5. Infrastructure for basic services Expensive but can be done
6. Empowered women Needs change in society’sattitudes, which can take a verylong time
7. ‘First call for children’ is inherent Usually difficult in short-term
8. Charismatic communityleadership
Either there or not ...
9. Poverty alleviation programs Expensive but can be done
10. No groups socially excluded(new)
Needs change in society’sattitudes, which can take a verylong time. But special programscould be done.
Factors from Jonsson (1995), see ‘How Nutrition Improves’, p 67.
Contextual Success Factorshpn/n2 -14
Figure 23
Table 4 Context in which selected community HNPs start and run.
0 worst 5 best
Country/period Period
(approx) Women’s status and education
social exclus-
ion
Community organization
literacy Level of health
And admin infrastruct
political commit-
ment
Total Minus
Pol comm
Total
Tanzania: Iringa starts
1984—90 2 4 4 3 2 5
15 20 declines 1990— 2 4 2 3 2 2 13 15 Zimbabwe: SFP starts
1981—90 2 4 5 2 2 5 15 20
declines 1990— 2 2 2 2 2 2 10 12 Bangladesh (BINP)
1997— 1 3 2 2 3 3
11 14 India (ICDS) 1975— 1 1 2 2 2 3 8 11 India (TINP) 1980—89 2 2 3 3 3 4
13 17 Indonesia: UPGK starts
1975— 2 4 3 2 2 4 13 17
declines 1990— 2 4 2 2 3 2 13 15 Philippines 1974— 4 4 3 4 3 1 19 20 Thailand 1982— 4 3 4 4 3 4 18 22 Costa Rica (Rural Hlth Prog)
1973— 4 4 4 3 4 4 19 23
Jamaica 1985— 4 4 3 4 4 4 19 23 Nicaragua 1979—90 3 2 3 3 3 4 14 18 Notes: women’s status and education can be quantified by indicators such as: adult literacy rates, females as % of males; secondary school enrollment for girls.
YEAR
00 95 90 85 80 75
%
50
40
30
20
10
0
Prevalences of underweight children,
< - 2SDs NCHS/WHO standards, 0-60 mo
Philippines
Indonesia
Thailand
Programs to improve nutrition …(meaning all those consequences for children, women, society, outlined earlier)
What?How?
Depends on …
Type of malnutrition
General (=protein-energy)
Acute (food crisis)
Micronutrient
Chronic Vitamin A (VAD)
Iron (anemia)
Iodine (I deficiencydisorders: IDDs)
By area/location
Local: Community-based and service delivery
Emergency
By socio-economic status
By biological status
Vertical
Interventions Groups affected
Source: Lancet nutrition series #3, 2008
Source: Lancet nutrition series #3, 2008
Programs: how?
Multiple (complementary) components within:
•CHNPS (community-based health and nutrition programs
•Service delivery (including IMCI)
•Central/vertical programs (e.g. fortification)
•Child Health Days
Main requirements/features for some components in localprogrammes.
ComponentSuitability of:
Community-based Service delivery,facility based
Local organization (e.g. VNWs) Antenatal care Infant feeding Growth monitoring Micronutrient supplementation Supplementary feeding Immunization, ORT Deworming Health referral NA
Day care —
Water/sanitation Microcredit —
Large scale programs
Effectiveness m&e, to build improvement and sustainability - VAC distribution - iodized salt
Trial/pilot -- Efficacy and acceptability research - VA fortification (esp. oil, otherwise with multi) - multi fortification of commercial foods - multi ‘sprinkles’ - multi supplementation esp. in pregnancy
Sequence of intervention development
Research and Development - iron fortification of staples, esp. rice - iron in salt