1 The role of micronutrients in the first 1,000 days of life Presented by Regina Moench-Pfanner, PhD ibn360 Pte Ltd, Singapore Information for Philippine Association of Nutrition (PAN), Inc. and Philippine Society of Nutritionist-Dietitians (PSND), Inc. Joint Convention, Manila 7 July, 2016

SCALE OF MALNUTRITION IN Source: IFPR Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by Washington, DC.

NUMBER OF CHILDREN STUNTED IN ASEAN Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF

PREVALENCE OF ANEMIA IN CHILDREN AND WOMEN Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF

GLOBAL NUTRITION TARGETS 5 Source: IFPR Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by Washington, DC.

THE FIRST 1000 DAYS ConceptionBirth6 months2 nd Birthday

MICRONUTRIENT MALNUTRITION (VMDS) WHAT IS IT? ►Micronutrient Malnutrition: Deficiencies in essential vitamins and minerals required in small amounts by the body including : Iron Vitamin A Iodine Zinc Folic Acid ►Deficiencies caused by: Insufficient, poor or unvaried diets Losses or poor absorption (due to infections like HIV/AIDS, malaria, diarrhea and parasites)

THE HEALTH SIGNIFICANCE OF VITAMINS AND MINERALS (MICRONUTRIENTS) Micro needed in small amounts Nutrients vitamins and minerals are needed by the body to perform hundreds of roles body cannot manufacture on its own in sufficient amounts must be consumed Some of the roles of micronutrients Growth (bone & muscle) Cognitive development Bolsters immune response Repairs cellular damage Energy metabolism Good health Healthy aging Good performance

VITAMINS – FAT SOLUBLE AND WATER SOLUBLE 9

WHAT FOODS ARE RICH IN MICRONUTRIENTS? 10 Water soluble vitamins (vitamin C and B complex) are rich in fruits and vegetables. Fat soluble carotenes – vitamin A precursors and others – are responsible for some of the colours of fruit and vegetables. Trace minerals are found in many foods but bioavailability is low from most plant sources. Vitamin D is found in few foods (cheese, margarine, butter, fortified milk, fortified cereals, fatty fish) unless fortified. The body makes vitamin D when exposed to ultraviolet rays. Milk and fish bones are also rich in calcium.

RECOMMENDED NUTRIENT INTAKE 11 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

12 Protein amino acids are essential for building, maintaining, and repairing new tissues; manufacturing important enzymes, hormones, antibodies, and other components; and performing specialized functions in regulating body processes; Quality protein from breast milk and/or complementary foods Lipids (EFAs) The brain is made primarily of fat (50-60% of the adult dry brain is fat) with AA and DHA being among the most important FA in the brain. The critical period for accretion of these fats into the infant’s brain is during the last trimester of gestation up to 2 years of age Supplementation with omega-3 fatty acids reduced risk of preterm birth (<34 weeks gestation) by 31% in all pregnancies and by 61% in high-risk pregnancies Vitamin A Needed before and during pregnancy to boost maternal vitamin A levels, immune system, and iron intake Intake through breast milk can improve Vitamin A status of nursing infants and lower mortality by 11% 40% reduction in vitamin A deficiency among 1-3 year olds Vitamin D An essential fat-soluble vitamin that is required for proper formation of bones and utilization of calcium and phosphorous in the body Zinc Supplementation improves immune function, reduces incidence of diarrhea and pneumonia - more LSFF research needed KEY NUTRIENTS BEFORE AND DURING 1,000 DAYS ARE CRUCIAL FOR LIFELONG POTENTIAL

Vitamin E A fat soluble vitamin that protects lipids and proteins from oxidation in the body, preventing the breakdown of tissues. Vitamin K Anti-haemorrhaging agent (promotes blood clotting) and maintains bone health Folic acid Adequate pre-pregnancy folate levels reduce incidence of spina bifida by 41% and reduce perinatal mortality due to NTDs by 66% Iodine Needed for fetal brain development and IQ, WHO states ID as most common preventable cause of early childhood mental deficiency Reduces risk of miscarriage and stillbirth Iron Reduces pregnancy complications, perinatal and maternal mortality related to iron deficiency anemia (hemorrhage) Can reduce anemia in <24 months by up to 62% Calcium An important mineral with a role in bone and tooth development, blood clotting and maintenance of healthy nerves and muscles. 13

THE FIRST 1000 DAYS ConceptionBirth6 months2 nd Birthday

PREGNANCY AND NUTRIENTS 15 ConceptionBirth

WHAT A PLATE SHOULD CONSIST OF 16 Many different foods Colourful Stomach filling Low in salt, unhealthy fat and refined sugar Pregnancy: increased micronutrient intake

WHAT A PLATE OFTEN CONSISTS OF 17

FOOD INADEQUACY 18 Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF

PREGNANCY: IRON AND FOLIC ACID SUPPLEMENTATION 19 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

IRON AND FOLIC ACID SUPPLEMENTATION IN PREGNANT WOMEN 20 Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF

THE FIRST 1000 DAYS ConceptionBirth6 months2 nd Birthday

LACTATION 22 Diversified nutritious adequate diet for lactating mothers Increased micronutrient intake Birth 6 months

PREGNANT AND LACTATING: IODINE SUPPLEMENTATION 23 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

COVERAGE OF IODIZED SALT 24 Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF

MULTIPLE MICRONUTRIENT SUPPLEMENTATIONI FOR PREGNANT AND LACTATING WOMEN 25 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

THE FIRST 1000 DAYS ConceptionBirth6 months2 nd Birthday

LACTATION AND COMPLEMENTARY FEEDING 27 Nutrient dense complementary foods as increased micronutrient needs for specific months of age Nutritious diversified diet for lactating mother Micronutrient increase in: B-vitamins, vitamin A, C Magnesium, calcium, phosphorus Zinc, Copper Iodine, Selenium (particularly for lactation beyond 4 months) 6 months 2 nd Birthday

UK: VITAMINS – RNI FOR CHILDREN (0-2Y) AND WOMEN (19-50Y) 0-6m7-9m10-12m1-3yWoman (19-50y)PregnancyLactation Vitamin A Vitamin D Vitamin K Vitamin E Vitamin C *70 Vitamin B *1 Vitamin B Vitamin B Vitamin B Vitamin B Vitamin B Vitamin B Folic Acid * For third trimester only Source: British Nutrition Foundation, Nutrition Requirements, FAO, Human vitamin and mineral requirements, Report of a joint FAO/WHO expert consultation,

UK: MINERALS – RNI FOR CHILDREN (0-2 YEARS) AND WOMEN (19-50 YEARS) Bulk minerals0-3m4-6m7-9m10-12m1-3yWoman (19-50y)PregnancyLactation Potassium (mg/d) Chloride (mg/d) Sodium (mg/d) Calcium (mg/d) Phosphorous Magnesium All minerals needed in the body are essential nutrients. Trace minerals0-3m4-6m7-9m10-12m1-3yWoman (19-50y)Pregnancy Lactation (≤4m) Lactation >4m) Iron (mg/d) Zinc (mg/d) Copper (mg/d) Iodine (µg/d) Selenium (µg/d) Source: British Nutrition Foundation, Nutrition Requirements, FAO, Human vitamin and mineral requirements, Report of a joint FAO/WHO expert consultation,

ECONOMIC LOSS DUE TO MICRONUTRIENT MALNUTRITION 30

INTERNATIONAL RECOMMENDATIONS 31

PRE-PREGNANCY: IRON AND FOLIC ACID SUPPLEMENTATION 32 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

PREGNANCY: IRON AND FOLIC ACID SUPPLEMENTATION 33 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

PREGNANCY: IRON AND FOLIC ACID (NON ANAEMIC) 34 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

PREGNANCY: VITAMIN A SUPPLEMENTATION 35 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

CALCIUM SUPPLEMENTATION 36 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

PREGNANT AND LACTATING: IODINE SUPPLEMENTATION 37 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

MULTIPLE MICRONUTRIENT SUPPLEMENTATIONI FOR PREGNANT AND LACTATING WOMEN 38 Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition

39 DIETARY FAT INTAKE FOR PREGNANT AND LACTATING WOMEN Source: International Society for the Study of Fatty Acids and Lipids. es_for_pregnant_and_lactating_wom en_bjn_2007.pdf es_for_pregnant_and_lactating_wom en_bjn_2007.pdf

TAKE HOME MESSAGES 40 Adequate nutrition is key during first 1,000 days of life – a requirement to meet global nutrition targets Diversified nutritious diet is key to provide required micronutrients – when difficult to obtain, food fortification should be used In early childhood the need for essential nutrients (i.e. iron, zinc) and essential amino acids is very high due to growth – foods need to be nutrient dense (fortified complementary foods) International recommendations on adequate nutrition, including micronutrients, exist for pregnancy, lactation and adequate complementary feeding – but difficulties to implement

Thank you

42 Information & correspondence: Regina Moench-Pfanner, PhD Chief Executive Officer, Ibn 360 Pte Ltd 3 Pickering Street, #02-36 Nankin Row, China Square Central, Singapore m t f