Conflict of Interest Disclosure The authors disclose having no conflict of interest to report in relation to this presentation

Homero Martinez Ian Darnton-Hill Daniel J. Raiten Application of Integration to Effective Implementation: “I-to-I:” Vitamin A Interventions Homero Martinez Ian Darnton-Hill Daniel J. Raiten

A Complex Health Context: it’s not just about too much or too little! Climate/Environmental Change Under-nutrition Nutrition Transition Malnutrition (over/under) Microbiome Inflammation Infectious Diseases Non-communicable Disease (DOHaD) Birth Death

A Comprehensive Approach is Needed Health Outcomes Clinical assessment/care Program M&E Environment Social/behavioral/ health systems context Diet/Nutrition Evidence-based interventions Food/ag systems

Basic research and knowledge translation: Inputs: nutrition biology/assessment/relevant bio-indicators of function/effect; Genomics/Metabolomics/exposome; Toxicology/pharmacology; Microbiome; Systems biology (human/plant/soil/food)  Collaborating disciplines: Nutrition science; Medicine (clinical/research); Food, animal science, agronomy, horticultural science; Plant biology, breeding; Soil science; Marine biology; Biotechnology; Microbiology; Agricultural engineering Physical/Environmental Sciences: Climatology; Geology/land use science; Soil science; Geo-spatial science Intervention/program development: Inputs: Nutritional assessment (Nutrient biomarkers; bio-indicators; Diagnostic platforms; food science including fortification options/bioavailability; Biotechnology options; Land use patterns/trends; Food/resource assessment, feasibility/acceptability studies  Collaborating disciplines: Clinical Care: Nutrition science; Medicine; Microbiology; Dietetics; Public health. Food science, biotechnology, agronomy, plant breeding, animal science, marketing, social/behavioral science, population dynamics  Intervention/program efficacy and implementation: Inputs: Social/behavioral public health context input from the implementation chain; community/country/regional; Environmental assessment  Collaborating disciplines: Population Based Sciences: Epidemiology; Implementation science; Agricultural economics M&E/Scaling up effective interventions/programs and monitoring/evaluation: Inputs: Improved surveillance; GPS/spatial technology; Global health indicators Enabling Communities: Policy makers; Public and private sector engagement - Understanding the implications of change: Social/behavioral sciences; Systems science  - Research agenda development and progression: Inputs: All: data and feedback from 1-5 Collaborating disciplines: All

What is “I – to – I”?

Goal of I-to-I Harmonize efforts to: Effectively respond to controversies that may arise as a result of experience, new knowledge or changing conditions on the ground, and, Create, implement and sustain evidence-informed, safe and efficacious interventions/policies/standards of care

Core Drivers of I-to-I To fully integrate nutrition into all aspects of health promotion, disease prevention and treatment: diet/exposure is just the first step in achieving healthy nutritional status, and, nutrition is a biological variable that serves as both an input and outcome to be considered as integral to all aspects of health promotion, disease prevention and treatment Translation of research findings to evidence-informed programs and policies is a process that involves a connection of multiple steps, disciplines and data inputs/outputs. A need exists for clear lines of communication and a platform to foster an integration of all relevant aspects of the continuum.

Biology and Assessment 1 Biology and Assessment 2 Interventions 3 Program: Roll-out/ scale-up 4 Stakeholder engagement Initial Components of the I-to-I Continuum, Linked to the MNF “Bridging” Concept

Evolving View of the Continuum of Effort Needed Basic biomedical/clinical/plant/animal science research: To understand the nature and mechanism of problems related to all aspect of human growth and development Knowledge Translation: Best practices in clinical assessment and surveillance to identify problems in individuals and populations Interventions: Sustainable, culturally and biologically relevant nutrition specific and nutrition sensitive interventions and programs

Evolving View of the Continuum of Effort Needed Implementation (roll-out/scale-up) involving the range of stakeholders at local/community, national and global levels. Monitoring and evaluation of programs/policies: Timely and appropriate change as needed. Data collection to give feedback at critical points throughout the continuum (i.e., research, translation, intervention development/revision, etc.), and, Creation of a critical interconnecting and continuous loop to enable responsiveness to changes anywhere along the chain, allowing for unintended consequences.

I-to-I: Iron Approach Issues: What do we know and need to know about iron biology to explain efficacy and safety concerns What factors influence safety and efficacy of available interventions Implications of concerns re: efficacy and safety for programs: Country experiences Implications for program and policy development and implementation Process: Four sessions were organized across the four tracks of the MNF global meeting in Ethiopia, 2014 Summaries of each session were compiled A peer-reviewed paper was published in Advances in Nutrition: Raiten, DJ et al. Integration to Implementation and the Micronutrient Forum: A Coordinated Approach for Global Nutrition. Case Study Application: Safety and Effectiveness of Iron Interventions. Adv Nutr. 2016 Jan 15;7(1):135-48

The Continuum: Evidence informed Interventions/programs and Policies:

Application of I-to-I: Interventions to Prevent/Treat Vitamin A Insufficiency

What’s the problem?: Global Vit. A Situation Prevalence Night blindness (in countries at risk) 5.17 million pre-school age children 9.75 million pregnant women Serum retinol <0.7 mcm0/l 190 million pre-school age children 19.1 million pregnant women Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vit. A deficiency.

Interventions to improve Vit. A status Current approaches Improving the availability and intake of vitamin A through dietary diversification Nutrition Education Better access to Vit. A rich foods Fortification of a staple food or condiment with vitamin A Periodic delivery of high-potency supplements 200 000 IU of vitamin A to preschool-age children (1 to <5 years of age) 100 000 IU of vitamin A to infants 6-11 months old 200 000 IU oral dose of vitamin A to mothers within six weeks after delivery

The Controversy related to Vit. A interventions The precipitating event: paper by Mason et al (Int J Epidemiol, 2014:1-10) The paper triggered different responses to address assessment/safety issues Who’s affected?

Objective of this symposium Today’s session is designed to highlight the need for a comprehensive approach to address Vit. A insufficiency, considering basic biology, clinical/population assessment, different interventions, and how these can be translated to appropriate programs and policies utilizing the I-to-I approach.

Thank you!