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. . How is DOHaD affecting policy? Dr. Chessa Lutter Principal Advisor Santiago de Chile, November 19-22, 2009 What does it take for DOHaD to influence policy? Is there a clear measure of population attributable risk (PAR) for health and the development of human capital ?

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Slide1 l.jpg
.

  • .

How is DOHaD affecting policy?

Dr. Chessa Lutter

Principal Advisor

Santiago de Chile, November 19-22, 2009


What does it take for dohad to influence policy l.jpg
What does it take for DOHaD to influence policy?

  • Is there a clear measure of population attributable risk (PAR) for health and the development of human capital?

  • Have interventions been identified that are efficacious and effective when delivered through existing health and social service platforms?

  • Do the interventions address social inequities in health and human capital?

  • Has there been an effective advocacy strategy to influence relevant technical and political agendas?

  • Was the strategy successful?


Slide3 l.jpg

Epigenetics? Concordant developmental changes in DNA methylation across chromosome 2 in two P21 vs P0 mouse hypothalamus MSAM cohybridizations

Cohybridization 1

Cohybridization 2

Wenjuan Zhang courtesy of Robert Waterman


It s a fat fat world l.jpg
It’s a FAT FAT WORLD methylation across chromosome 2 in two P21 vs P0 mouse hypothalamus MSAM cohybridizations

FAT Kids

Urban dog: too fat to walk?

Urban black bear behind fast-food restaurant: the new couch potato?

FAT Daddys


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What proportion of adult disease is explained by DOHaD versus the environment in which we live and eat and move (or don’t move enough)?

Developmental origins of adult disease

Obesigenic environment

Interaction ?

Wenjuan Zhang courtesy of Robert Waterman


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Severe acute malnutrition versus the environment in which

Stunting

8.1 cm

Marasmas

Kwashiorkor

Age: 2 y 9 m

Weight: 10.7 kg.

Height: 78.3 cm

2 y 6 m

11.6 kg

86.4 cm

Photo credit: Lancet

Photo credit: UNICEF, Perú


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Critical period to prevent linear growth retardation versus the environment in which

0.5

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0

0

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-0.5

-1

-1

-1.5

-1.5

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-2

-1 + 2 years

-1 y + 2

Z

-2.5

0

3

5

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27

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31

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35

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59

Age (months)

Africa

Latin America and Caribbean

Asia

Source: Shrimpton, R. et al, 2001. http://www.pediatrics.org/cgi/content/full/107/5/e75


Prevalence of stunting to low weight for age 2 ds in children 5 years l.jpg
Prevalence of stunting to low weight for age (<-2 DS) in children < 5 years

%

3.0

6.2

4.5

Source: OPS. Desnutrición en Infantes y Niños Pequeños en América Latina y El Caribe:

Alcanzando los Objetivos del Desarrollo del Milenio. Washington: 2008


Slide9 l.jpg

Distribution of Z scores of Guatemalan children children < 5 years

< 5 years (2002)

Weight/age

Weight/length

Length/age

Obese

Stunted


Tendencies in the prevalence of stunting by country and year of survey l.jpg
Tendencies in the prevalence of stunting, by country and year of survey

2008

1989

1994

1998

2003

1986

1995

2000

2005

1986

1991

1996

2002

1987

1995

1999

2002

1995

2000

2005

1986

1996

2000

2007

Source: OPS. Malnutrición en infantes y niños pequeños en América Latina y El

Caribe: Alcanzando los Objetivos de Desarrollo del Milenio. Washington DC. 2008


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Prevalence of stunting by year of survey year of survey

and maternal education

=59.3%

=62.3%

Source: OPS. Malnutrición en infantes y niños pequeños en América Latina y El

Caribe: Alcanzando los Objetivos de Desarrollo del Milenio. Washington DC. 2008


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Short-term consequences year of survey

Mortality, morbidity, disability

Long-term consequences:

Adult size, intellectual ability, economic productivity, reproductive performance, metabolic CHD

Maternal and child undernutrition

Immediate

causes

Inadequate dietary intake

Disease

Household food

insecurity

Unhealthy hh environment & lack of health services

Inadequate care

Income poverty:

Employment, self-employment, dwelling, assets, remittances, pensions, transfers, etc

Underlying

causes

Lack of capital: financial, human, physical, social, and natural

Basic

causes

Social, economic,

and political context

UNICEF Conceptual model


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The role of infectious disease in child growth year of survey

Source: Mata L. The Children of Santa Maria Caique, 1983.


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Policy driver: The effect of malnutrition year of surveyand human capital

The causal relationship between poverty and malnutrition

The causal relationship between malnutrition and poverty

INCAP longitudinal study and work of Reynaldo Martorell


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Decline in the prevalence of stunting in Brazil, year of survey

1996-2006

50%

1996

2006

Source: Monteiro et al., Causes for the decline in child undernutrition in Brazil, 1996-2007 Rev Saude Pública 2009;43(1)


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Explanatory factor for the decline in stunting in Brazil, 1996-2006

=63.3%

Source: Monteiro et al., Causes for the decline in child undernutrition in Brazil,

1996-2007 Rev Saude Pública 2009;43(1)


Breastfeeding l.jpg
Breastfeeding 1996-2006

Photo credit: João Aprigio Guerra de Almeida, Fundación Fiocruz, Brasil


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Breastfeeding promotion cited as the most effective preventive intervention to prevent under-5 mortality

From Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival

Study Group. How many child deaths can we prevent this year? The Lancet 2003;362:65-71.


The importance of health worker training and counseling on exclusive breastfeeding l.jpg
The importance of health worker training and preventive intervention to prevent under-5 mortality counseling on exclusive breastfeeding

3 months

5 months

10-180

days

6 months

%

Source: OPS. Malnutrición en los niños pequeños en América Latina y el Caribe: Alcanzando los Objetivos de Desarrollo del Milenio. Washington 2008.


Slide22 l.jpg

Effects on human capital development preventive intervention to prevent under-5 mortality

Washington Post 2002;

Mortenson et al., 2002

WHO. Horta et al., Geneva 2007.

www.who.int/child_adolescent_health/documents/9241595230/en/index.html


Policies and programs to support breastfeeding l.jpg
Policies and programs to support breastfeeding preventive intervention to prevent under-5 mortality

  • International Code of Marketing of Breast-milk Substitutes (WHO 1981)

  • Innocenti Declaration (1990) and approval at the 45th World Health Assembly

  • Baby Friendly Hospital Initiative (WHO/UNICEF,1992)

  • Capacity development in clinical management of common BF problems (USAID financed Wellstart International, 1983-1998)

  • Global Strategy for Infant and Young Child Feeding and approval by the World Health Assembly (2003)

  • WHO Child Growth Standards (2006)


Changes in medium duration of breastfeeding latin american and caribbean countries 1986 2004 l.jpg
Changes in medium duration of breastfeeding: preventive intervention to prevent under-5 mortalityLatin American and Caribbean countries, 1986-2004

17.3

17.3

21.6

21.6

20.6

20.6

14

14

19.6

19.6

20.3

20.3

Months

19.9

19.9

16.2

16.2

20.6

20.6

11.8

11.8

21.6

21.6

9

9

Country


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Porcentaje de gasto total (%) y gasto (US$) en la promoción de LM

comparado a otros temas en nutrición materno-infantil, 1999-2005

Fuente: Academy for Educational Development. LINKAGES Final Report. Washington DC: 2006. (Expenditures are adjusted for inflation using the Gross Domestic Product Implicit Price Deflator of 2000).


Slide26 l.jpg

What have we learned and what do we still promoción de LM

need to know?

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0

-0.5

-0.5

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-1

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-1.5

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-2

Maternal nutrition ?

-1 y + 2

-1 + 2 years

Z

-2.5

0

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59

Age (months)

Africa

Latin America and Caribbean

Asia

Source: Shrimpton, R. et al, 2001. http://www.pediatrics.org/cgi/content/full/107/5/e75


What does it take for dohad to influence policy27 l.jpg
What does it take for DOHaD to influence policy? promoción de LM

  • Is there a clear measure of population attributable risk (PAR) for health and the development of human capital?

  • Have interventions been identified that efficacious and effective when delivered through existing health and social service platformsor by addressing fundamental political and social inequities?

  • Do the interventions address social inequities in health and human capital?

  • Has there been an effective advocacy strategy to influence relevant technical and political agendas?

  • Was it successful?


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