The challenge of maternal and child nutrition globally: how can we contribute?

1. The challenge of maternal and child nutrition globally: how can we contribute? Zulfiqar A. Bhutta Founding Chair Women & Child Health The Aga Khan University

2. Under-Five Mortality Rate in 2011(7.2 million under 5 deaths) IHME ( Lancet 2011)

3. Global distribution of disease burden attributable to 20 selected risk factors Underweight Unsafe sex High blood pressure Tobacco Alcohol Unsafe water, sanitation & hygiene High cholesterol Indoor smoke from solid fuels Iron deficiency High BMI Zincdeficiency Low fruit and vegetable intake Vitamin A deficiency Physical inactivity High-mortality developing Occupational injury Lower-mortality developing Lead exposure Illicit drugs Developed Unsafe health care injections Lack of contraception Childhood sexual abuse 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% Attributable DALY (% of global DALY - Total 1.46 billion) Source: Ezzati M et al., Lancet 2002

4. Global distribution of disease burden attributable to 20 selected risk factors Underweight Unsafe sex High blood pressure Tobacco Alcohol Unsafe water, sanitation & hygiene High cholesterol Indoor smoke from solid fuels Iron deficiency High BMI Zincdeficiency Low fruit and vegetable intake Vitamin A deficiency Physical inactivity High-mortality developing Occupational injury Lower-mortality developing Lead exposure Illicit drugs Developed Unsafe health care injections Lack of contraception Childhood sexual abuse 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% Attributable DALY (% of global DALY - Total 1.46 billion) Source: Ezzati M et al., Lancet 2002

5. 171 Million Children Under 5 are Stunted Prevalence of Stunting

6. The 20 Countries with 80% of Global Childhood Stunting

7. Faces of “Hidden Hunger” Iron Deficiency Zinc Deficiency Ca deficiency Rickets Iodine Deficiency Vitamin A Deficiency

8. Relative Risks for Vitamin A & Zinc Deficiency and Child Mortality Vitamin A - Diarrhea 1.47 (1.25-1.75) - Measles 1.35 (0.96-1.89) Zinc - Diarrhea 1.09 (1.01-1.18) - Pneumonia 1.25 (1.09-1.43) - Malaria 1.56 (1.29-1.89) • Black et al, Lancet 2008

9. Undernutrition Begins with the Mother

10. Where are LBW infants born ? Industrialized countries Incidence 7% Burden 4%; 0.8 m Incidence 28% Burden 54%; 11 m Incidence 14% Burden 19%; 4 m Incidence 14% Burden 19%; 4 m 96% of LBW births are in low/middle income countries 90% of LBW births are in Africa and Asia

11. High Prevalence of IUGR, Stunting and Severe Wasting in Children Under 5

12. The Vicious Cycle of Malnutrition and Poverty Income poverty Low quality food intake (micronutrients) Frequent infections Physical labor Frequent pregnancies Increased nutrient loss & utilization Malnutrition Low productivity from poor physical performance Loss in productivity from poor cognitive development & schooling Increased health care costs of ill health

13. Overall and Cause-Specific Mortality Risk for Stunting in Children <5y Old

14. Together these risk factors are responsible for more than one-third—about 35%—of child deathsand 11% of the global total disease burden The Burden of Maternal and Child Undernutrition

15. Key Messages Global Burden of Undernutrition

17. Global Growth Faltering Window of opportunity Victora et al, Pediatrics 2010

19. BMI – Mothers of Index Children - Provinces

21. The nature of poverty “ We think sometimes that poverty is only being hungry, naked and homeless. The poverty of being unwanted, unloved and uncared for is the greatest poverty .…” Mother Teresa

22. IYCF Indicators – National (Cont.)

23. Feeding Practices During Diarrhea Liquids Offered (compared to usual) Food offered (compared to usual) 56% 21% of children are given more liquids than usual during diarrhoea, as recommended 2006-07 PDHS, NIPS and Macro International

25. New sources of information • BMC Public Health Special issue on LiST interventions (March 2011) • Lancet Stillbirth series (March 2011) • Cochrane Library & 3ie/DFID/BMGF reviews

26. Breastfeeding Maternal Nutrition Nutritional Care of Sick Child Complementary Feeding w/ BF Iodine suppl Vitamin A supplements Control of Anemia Essential Nutrition Actions

27. 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 diarrhea • Vitamin A fortification or supplementation • Universal salt iodization • Handwashing or hygiene interventions • Treatment of SAM

29. Impact of Community-based Intervention Packages on Initiation of Early Breast-feeding Source: Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal. Cochrane Database of Systematic Reviews 2010

30. Individual vs Group Counseling (EBF rates at 6 months) 38% increase (22-56%) 67% increase (23-126%)

31. 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

33. Local production of ready-to-use therapeutic foods offers great promise

34. Who speaks for family planning? "Family planning is to maternal health what immunization is to child health" Khama Rogo (World Bank)

35. National Efforts

36. Coverage Is Important !

37. Coverage Is Important !

38. Coverage Is Important !

39. National Efforts

40. Priority Action Areas • Link maternal and infant nutrition • Scale up orphan interventions (Balanced Energy Protein supplementation for women of reproductive age, Complementary Feeding support in food insecure populations) • Community delivery platforms for nutrition • Link preconception care to nutrition • Adolescent nutrition • Folic acid fortification