BEST Practices Intervention based on
The Lancet’s Series on Maternal and
Child Undernutrition 2008 dan 2013
Abdul Razak Thaha IGI – Institut Gizi Indonesia
Fakultas Kesehatan Masyarakat Universitas Hasanuddin
KPIG, Temu Ilmiah Internasional dan Kongres Nasional PERSAGI XX The Sahid Jogja Hotel, Yogyakarta 25-30 November 2014
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IUGR, Stunting and Severe Wasting
Together were responsible for more than one-third—about
35%—of child deaths and 11% of the global total disease burden
More than 3.6 million mothers and children die each year as a result of undernutrition
The very high mortality and disease burden resulting from these nutrition-related factors
make a compelling case for the urgent implementation of proven interventions
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Long-Term Effects of Early Undernutrition
There is relationships between indices of maternal and child undernutrition (maternal height, birthweight, IUGR, and weight, height, and body-mass index at 2 years) and adult outcomes (height, schooling, income, offspring bodyweight, body-mass index, glucose concentrations, blood pressure)
In the low-and middle-income countries, these relationships related to blood lipids, cardiovascular disease, lung and immune function, cancers, osteoporosis and mental illness
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Stunting Increases Chronic Disease Risk as Adults
Stunting in the first 2 years leads to irreversible damage into adult life
Young children who are undernourished and gain weight rapidly laterare at high risk of
nutrition-related chronic diseases
No evidence that rapid weight or length gain in first 2 years of lifeincreases the risk of
chronic disease
The prevention of maternal and child undernutrition is a long-terminvestment that will benefit the current generation and their
children
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Evidence-Based Interventions
Systematic review
of efficacy or effectiveness of 45
possible interventions that
affect maternal and child undernutrition and nutritionrelated
outcomes, including:
1. Breastfeeding promotion
2. Complementary feeding
promotion
3. strategies with or without
provision of food supplements
4. Micronutrient interventions
(fortification &
supplementation)
5. General supportive strategies
for improving family and
community nutrition and
disease burden reduction
6. Interventions for the treatment
of severe acute malnutrition
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Interventions with Sufficient Evidence to Implement in All Countries
Maternal and Birth
Outcomes
• Iron folate supplementation
• Maternal supplements of multiple micronutrients
• Maternal iodine through iodization of salt
• Maternal calcium supplementation
• Interventions to reduce tobacco consumption or indoor air pollution
Newborn Babies
• Promotion of breastfeeding (individual and group counseling)
Infants and Children
• Promotion of breastfeeding (individual And group counseling)
• Behavior change communication for improved complementary feeding
• Zinc supplementation
• Zinc in management of diarrhe
• Vitamin A fortification or supplementation
• Universal salt iodization
• Handwashing or hygiene interventions
• Treatment of SAM
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Interventions with Sufficient Evidence to Implement in Specific Situational Contexts
Maternal and Birth
Outcomes
• Maternal supplements of balanced energy and protein
• Maternal iodine supplements
• Maternal deworming in pregnancy
• Intermittent preventative treatment for malaria
• Insecticide-treated bednets
Newborn Babies
• Neonatal vitamin A supplementation
• Delayed cord clamping
Infants and Children
• Conditional cash transfer programs (with nutritional education)
• Deworming
• Iron fortification and supplementation programs
• Insecticide-treated bednets
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Evidence-Based Interventions
• Breastfeeding promotion
• Appropriate complementary feeding
• Supplementation with vitamin A and zinc
• Appropriate management of severe acute malnutrition
Interventions showing the most promise for reducing child deaths and future disease burden include:
Conception through 24 months is the critical window of opportunity to
prevent and intervene to reduce stunting IGI
Key Challenges at National Level
1 2 3 4 5 6 7
Not Doing the Wrong Things
Getting Nutrition on the National Agenda
Doing the Right Things
Using Data for Nutrition Decision Making
Building Strategic and Operational Capacity
Using Data for Nutrition Decision Making
Building Strategic and Operational Capacity
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Social, Economy and Politics Support National nutrition programs should effectively monitor and
evaluate target populations that benefit most from interventions—pregnant women and children under 2
Countries should focus resources on interventions with proven effectiveness and implement them at scale as
quickly as possible
Economic and social policies addressing poverty, trade and agriculture associated with rapid improvements in
nutritional status should also be implemented
Governments should look to incorporate nutrition goals into programs that may not directly address health, but
that could benefit from improved national nutrition
Nutrition is a central component for human, social and economic development
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Nutrition Interventions Reviewed Lancet 2013
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Women of reprod age and pregnancy
• Folic acid suppl.
• Iron and iron-folate suppl.
•MMN suppl.
•Calcium suppl.
• Iodine through iodisation of salt
•Maternal supplementation with balanced energy Protein
Neonates
•Delayed cord clamping
•Neonatal vitamin K administration
•Vitamin A supplementation
•Kangaroo mother care and promotion of breastfeeding
Infants and young children
• IYCF promotion
•Preventive vitamin A suppl ( 6 -59 months)
• Iron suppl.
•MMN suppl.
• Zinc suppl.
•Management of MAM
•Management of SAM
Disease prevention and management
•WASH interventions
•Maternal drowning
•Deworming in children
• Feeding practices in diarrhoea
• Zinc therapy for diarrhoea
• IPTp/ITN for malaria in pregnancy
•Malaria prophylaxis in Children
2013 IGI
Nutrition-sensitive Interventions and Programmes Lancet 2013
• Agriculture and food security
• Early child development
• Women’s empowerment
• Schooling
• Health & family planning services
• Social safety nets
• Maternal mental health
• Child protection
• Water, sanitation & hygiene
Interventions or programmes that address the underlying determinants
of fetal and child nutrition and development (food, care, health) and
incorporate specific nutrition goals and actions.
Nutrition-sensitive programmes can serve as delivery platforms for
nutrition-specific interventions, potentially increasing their scale, coverage
and effectiveness.
Morbidity and Mortality in Childhood
Benefits during the life course
Cognitive, motor, socioemotional development
School performance and learning capacity
Adult Status
Obesity and NCDs
Work capacity and productivity
Nutrition specific interventions and programmes Adolescent health and
preconception nutrition Maternal dietary
supplementation Micronutrient
supplementation or fortification
Breastfeeding and complementary feeding
Dietary diversification Feeding behaviors and
stimulation Treatment of serves acute
malnutrition Disease prevention and
management Nutrition interventions in
emergencies
Nutrition sensitive programmes and approaches Agriculture and Food Security Social safety nets Early child development Maternal mental health Women’s empowerment Child protection Classroom education Water and sanitation Health ans family planning services
Building an enabling environment Rigorous evaluation Advocacy strategies Horizontal and vertical
coordination Accountability incentives
regulation, legislation Leadership programmes Capacity investments Domestic resource
mobilitation
Breastfeeding nutrient rich foods and eating routine
Feeding and caregiving practice, parenting, stimulation
Low burden of infectious diseases
Optimum fetal and child nutrition and development
Knowledge and evidence Politics and government
Leadership, capacity and financial resources Social, economic, and environmental context (national and global)
Food security, including availability, economic access, and use of food
Feeding and caregiving resources (maternal, household, and community levels)
Access to and use of health services, a safe and hygienic environment
Black .RE et al, The 2013 Lancet Series on Maternal and Child Nutrition
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Building an enabling environment
Rigorous evaluation
Advocacy strategies
Horizontal and vertical coordination
Accountability incentives regulation, legislation
Leadership programmes
Capacity investments
Domestic resource mobilitation
• Knowledge and evidence
• Politics and government
• Leadership, capacity and financial resources
• Social, economic, and environmental context (national and global)
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Nutrition sensitive programmes and approaches
Agriculture and Food Security Social safety nets Early child development Maternal mental health Women’s empowerment Child protection Classroom education Water and sanitation Health ans family planning services
• Food security, including availability, economic access, and use of food
• Feeding and caregiving resources (maternal, household, and community levels
• Access to and use of health services, a safe and hygienic environment
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Nutrition specific interventions and programmes
Adolescent health and preconception nutrition
Maternal dietary supplementation
Micronutrient supplementation or fortification
Breastfeeding and complementary feeding
Dietary diversification
Feeding behaviors and stimulation
Treatment of serves acute malnutrition
Disease prevention and management
Nutrition interventions in emergencies
• Breastfeeding, nutrient rich foods and eating routine
• Feeding and caregiving practice, parenting, stimulation
• Low burden of infectious diseases
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TUJUAN PEMBELAJARAN
OPTIMUM FETAL AND CHILD
NUTRITION AND DEVELOPMENT
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MORBIDITY & MORTALITY MATERNAL AND CHILDHOOD
COGNITIVE, MOTOR, SOCIOEMOTIONAL DEVELOPMENT
SCHOOL PERFORMANCE & LEARNING CAPACITY
ADULT STATURE OBESITY & NCDs
WORK CAPACITY & PRODUCTIVITY
Benefits during the life course
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Preconception care family planning ,delayed age of first pregnancy, prolonging of inter-pregnancy interval, abortion care, psychosocial care
• Folic acid supplementation
• Multiple micronutrient supplementation
• Calcium supplementation
• Balanced energy protein supplementation
• Iron or Iron plus folate • Iodine supplementation • Tobacco cessation
• Delayed card damping • Early initiation of breast
feeding • Vitamin K administration • Neonatal Vitamin A
supplementation • Kangaroo mother care
• Exclusive breast feeding • Complementary feeding • Vitamin A
supplementation (6-59 months)
• Preventive zinc supplementation
• Multiple micronutrient supplementation
• Iron supplementation
Adolescent WRA and Pregnancy
Neonates Infants and
Children
Disease prevention and treatment
• Malaria prevention in women
• Maternal deworming
• Obesity prevention
Disease prevention and treatment
Management of SAM Management of MAM • Therapeutic zinc for
diarrhea • WASH • Feeding in diarrhea • Malaria prevention
in children • Deworming in
children • Obesity prevention
Decreased maternal and childhood morbidity and mortality Improved cognition growth and neurodevelopmental outcomes
Increased work capacity and productivity Economic developmen
Delivery platform, Community delivery platforms, integrated management of childhood illnesses, child health days, school based delivery platforms, financial flatforms, fortification strategies, nutrition in emergency
Bold-interventions modelled Italic-Other intervention reviewed WRA-women of reprductive age. WASH-water, sanitation, and hygiene. SAM-severe acute malnutrition. MAM-moderate AM.
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Adolescent
• Preconception care family planning ,
• delayed age of first pregnancy,
• prolonging of inter-pregnancy interval,
• abortion care,
• psychosocial care
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WRA and Pregnancy
• Folic acid supplementation
• Multiple micronutrient supplementation
• Calcium supplementation
• Balanced energy protein supplementation
• Iron or Iron plus folate
• Iodine supplementation
• Tobacco cessation
Disease Preventon and Treatment
• Malaria prevention in women
• Maternal deworming
• Obesity prevention
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Neonatus
• Delayed card damping
• Early initiation of breast feeding
• Vitamin K administration
• Neonatal Vitamin A supplementation
• Kangaroo mother care
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Infants and Children
• Exclusive breast feeding
• Complementary feeding
• Vitamin A supplementation (6-59 months)
• Preventive zinc supplementation
• Multiple micronutrient supplementation
• Iron supplementation
Disease Prevention and Treatment:
• Management of SAM
• Management of MAM –Therapeutic zinc for diarrhea
–WASH
–Feeding in diarrhea
–Malaria prevention in children
–Deworming in children
–Obesity prevention
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Delivery platform
• Community delivery platforms,
• integrated management of childhood illnesses,
• child health days,
• school based delivery platforms,
• financial platforms,
• fortification strategies, nutrition in emergency
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2008 Series
• Identified need to focus on first 1000
days of life
• Called for greater attention to
national nutrition programmes,
integration with health programmes
and inter-sectoral approaches.
• Specific and Sensitive Intervention
2013 Series
• Re-evaluated problems of maternal
and child undernutrition
• Considered growing problem of
overweight and obesity
• Assessed the current and needed
national and global response since
2008
Shifts in the Nutrition Landscape
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The Benefit of the First 1000 Days of Life
“The building blocks of adult health and productivity begin before conception and take shape very early in life. The notion of the first 1000 days (conception through to 24 months of age) has attracted
attention as the blueprint for lifespan trajectories. When threats such as undernutrition and environmental stress occur, lifespan trajectories
can be disrupted, resulting in poor school performance, reduced economic opportunities, and chronic health problems. As these
conditions extend into the reproductive years and adulthood, they afect subsequent generations, perpetuating a negative cycle of
economic and health disparities. The first 1000 days provide sensitive opportunities for interventions that can prevent early threats and
protect children from lifelong negative consequenses”
-Lancet, Vol. 384, October 4, 2014-
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THANK YOU
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