Thinking about Programming to Reduce Chronic Malnutrition in Infants and Young Children Judy Canahuati, USAID with thanks to Mary Arimond, IFPRI and Martin Bloem, WFP Judy Canahuati, USAID with thanks to Mary Arimond, IFPRI and Martin Bloem, WFP Interaction, May 9, 2008 Photo: CARE USA

OutlineOutline Window of opportunity: conception- 24 monthsWindow of opportunity: conception- 24 months Why does growth falter?Why does growth falter? Poverty and malnutritionPoverty and malnutrition Prevention vs. curePrevention vs. cure Guiding Principles for feedingGuiding Principles for feeding Problem nutrients; nutrient gapsProblem nutrients; nutrient gaps Options for filling the gapsOptions for filling the gaps Window of opportunity: conception- 24 monthsWindow of opportunity: conception- 24 months Why does growth falter?Why does growth falter? Poverty and malnutritionPoverty and malnutrition Prevention vs. curePrevention vs. cure Guiding Principles for feedingGuiding Principles for feeding Problem nutrients; nutrient gapsProblem nutrients; nutrient gaps Options for filling the gapsOptions for filling the gaps

Chronic malnutrition begins early* *Lancet series on Nutrition WB Repositioning Nutrition as Central to Development, *Lancet series on Nutrition WB Repositioning Nutrition as Central to Development,

Period of most rapid growth and vulnerability to growth faltering Period of most rapid growth and vulnerability to growth faltering Shrimpton et al Age (months)Age (months)

Rice consumption and rice prices Torlesse, Kiess and Bloem J. Nutr. 133: , May 2003

Malnutrition rates and Rice prices Torlesse, Kiess and Bloem J. Nutr. 133: , May 2003

Non-rice food expenditure and malnutrition Torlesse, Kiess and Bloem J. Nutr. 133: , May 2003

Choices and economic status Very, very poor Less poor Not poor Moderate poor Very poor Rice Rice Rice and vegs Rice Rice Rice and eggs Rice and vegs Rice and eggs Rice and meat Rice Rice and vegs Rice,vegs, and eggs Rice, vegs, and eggs Rice, vegs, eggs, meat

Greatest benefits from nutrition interventions in first 2-3 years (Guatemala) Annual length gain (mm) 0-36 mo36-84 mo Schroeder, D., Martorell, R., Rivera, J., Ruel, M.T. and Habicht, J.P. Age differences in the impact of supplementation on growth Age differences in the impact of supplementation on growth J. Nutr. 125 (suppl):1060S-1067S, 1995 J. Nutr. 125 (suppl):1060S-1067S, 1995 Courtesy IFPRI Annual change in length by age, with consumption of an additional 100 kcal/d of high-energy/protein supplement Age

Prevention can be more effective than cure Prevention can be more effective than cure P=0.10 P<0.05 P<0.05 Random effects logit models (adj. for cluster effects and controlling for age, sex) 4pp6pp 4pp Ruel et al., 2008 Courtesy IFPRI

Underweight trends among children* in target areas in GINA II countries MozambiqueUgandaNigeria GINA II GINA II Average Average Baseline Final 52% 9% Baseline Final 21.2 % 10.2% Baseline Final 24.6% 22.9% Baseline Final 32.4 % 14.1% 82 % reduction in severely and moderately underweight children *Children <59 months who have a weight-for-age score below -2 SD based on NCHS/CDC/WHO reference population. 52% reduction in severely and moderately underweight children 7.5 % reduction in severely and moderately underweight children 57% reduction in severely and moderately underweight children Chikodzore, Downer & Tanamly Evaluation GINA II

Some Nutritional Programmatic alternatives Global Strategy for Infant and young child feeding and Family foods for breastfed child (WHO)Global Strategy for Infant and young child feeding and Family foods for breastfed child (WHO) ENA (Essential Nutrition Actions)ENA (Essential Nutrition Actions) AIN (Integral attention to the child)AIN (Integral attention to the child) WV Preventive MethodWV Preventive Method GINA II Model of integrating agriculture and nutritionGINA II Model of integrating agriculture and nutrition PD/HearthPD/Hearth CMAM (Community Management of Acute Malnutrition)CMAM (Community Management of Acute Malnutrition) Global Strategy for Infant and young child feeding and Family foods for breastfed child (WHO)Global Strategy for Infant and young child feeding and Family foods for breastfed child (WHO) ENA (Essential Nutrition Actions)ENA (Essential Nutrition Actions) AIN (Integral attention to the child)AIN (Integral attention to the child) WV Preventive MethodWV Preventive Method GINA II Model of integrating agriculture and nutritionGINA II Model of integrating agriculture and nutrition PD/HearthPD/Hearth CMAM (Community Management of Acute Malnutrition)CMAM (Community Management of Acute Malnutrition)

Guiding Principles for Feeding Infants and Young Children Provide a framework for understanding, assessing, and improving infant and young child feedingProvide a framework for understanding, assessing, and improving infant and young child feeding Developed first for breastfed children (PAHO/WHO, 2001) and then for non- breastfed (WHO, 2005)Developed first for breastfed children (PAHO/WHO, 2001) and then for non- breastfed (WHO, 2005) Cover age range of 0-24 monthsCover age range of 0-24 months Provide a framework for understanding, assessing, and improving infant and young child feedingProvide a framework for understanding, assessing, and improving infant and young child feeding Developed first for breastfed children (PAHO/WHO, 2001) and then for non- breastfed (WHO, 2005)Developed first for breastfed children (PAHO/WHO, 2001) and then for non- breastfed (WHO, 2005) Cover age range of 0-24 monthsCover age range of 0-24 months

Multiple dimensions of infant and young child feeding If breastfed: Breastfeed exclusively to 6 months, then introduce complementary foodsBreastfeed exclusively to 6 months, then introduce complementary foods Continue on-demand breastfeeding until 24 months or beyondContinue on-demand breastfeeding until 24 months or beyond If not breastfed: Meet childs fluid needs with safe fluids, including clean waterMeet childs fluid needs with safe fluids, including clean water Both: Practice responsive feedingPractice responsive feeding Practice good hygiene and food handlingPractice good hygiene and food handling Ensure that energy needs are metEnsure that energy needs are met If breastfed: Breastfeed exclusively to 6 months, then introduce complementary foodsBreastfeed exclusively to 6 months, then introduce complementary foods Continue on-demand breastfeeding until 24 months or beyondContinue on-demand breastfeeding until 24 months or beyond If not breastfed: Meet childs fluid needs with safe fluids, including clean waterMeet childs fluid needs with safe fluids, including clean water Both: Practice responsive feedingPractice responsive feeding Practice good hygiene and food handlingPractice good hygiene and food handling Ensure that energy needs are metEnsure that energy needs are met Continued…….

Multiple dimensions of infant and young child feeding, cont. Both breastfed & non-breastfed: Gradually increase consistency and variety as infant developsGradually increase consistency and variety as infant develops Feeding frequency: 2-3 times plus snacks (BF), 4-5 times (non-BF) plus snacksFeeding frequency: 2-3 times plus snacks (BF), 4-5 times (non-BF) plus snacks Sufficient energy density of foods (e.g. thick vs.watery gruels)Sufficient energy density of foods (e.g. thick vs.watery gruels) Feed a variety of foods to ensure all nutrient needs are metFeed a variety of foods to ensure all nutrient needs are met Feed specially fortified foods and/or give supplements to fill gapsFeed specially fortified foods and/or give supplements to fill gaps Feed appropriately during and after illnessFeed appropriately during and after illness Both breastfed & non-breastfed: Gradually increase consistency and variety as infant developsGradually increase consistency and variety as infant develops Feeding frequency: 2-3 times plus snacks (BF), 4-5 times (non-BF) plus snacksFeeding frequency: 2-3 times plus snacks (BF), 4-5 times (non-BF) plus snacks Sufficient energy density of foods (e.g. thick vs.watery gruels)Sufficient energy density of foods (e.g. thick vs.watery gruels) Feed a variety of foods to ensure all nutrient needs are metFeed a variety of foods to ensure all nutrient needs are met Feed specially fortified foods and/or give supplements to fill gapsFeed specially fortified foods and/or give supplements to fill gaps Feed appropriately during and after illnessFeed appropriately during and after illness

Problem nutrients for infants & young children* Vitamin ACalcium ThiaminIron RiboflavinZinc Vitamin B6 Folate Non-BF: B12** * Vitamin C Vitamin ACalcium ThiaminIron RiboflavinZinc Vitamin B6 Folate Non-BF: B12** * Vitamin C **Dewey, 2005, GP Non-BF, pp.15, 20

Nutrient gaps for 6-24 mo 10-site (9-country) study identified gaps in nutrient intakes for non-BF and in nutrient density of complementary food for BF10-site (9-country) study identified gaps in nutrient intakes for non-BF and in nutrient density of complementary food for BF Multiple micronutrient gaps in all sitesMultiple micronutrient gaps in all sites Gaps were greatest for youngest (6-8 mo)Gaps were greatest for youngest (6-8 mo) Some nutrients (e.g. vitamin A) were problematic in some sites but not othersSome nutrients (e.g. vitamin A) were problematic in some sites but not others Some were problematic in most or all sites (e.g. iron; size of gap between desired and actual also greatest for iron)Some were problematic in most or all sites (e.g. iron; size of gap between desired and actual also greatest for iron) 10-site (9-country) study identified gaps in nutrient intakes for non-BF and in nutrient density of complementary food for BF10-site (9-country) study identified gaps in nutrient intakes for non-BF and in nutrient density of complementary food for BF Multiple micronutrient gaps in all sitesMultiple micronutrient gaps in all sites Gaps were greatest for youngest (6-8 mo)Gaps were greatest for youngest (6-8 mo) Some nutrients (e.g. vitamin A) were problematic in some sites but not othersSome nutrients (e.g. vitamin A) were problematic in some sites but not others Some were problematic in most or all sites (e.g. iron; size of gap between desired and actual also greatest for iron)Some were problematic in most or all sites (e.g. iron; size of gap between desired and actual also greatest for iron) Working group on Infant and Young Child Feeding Indicators, 2006

Filling the gap Fortified commodities have a role to playFortified commodities have a role to play As currently formulated, dont fill the gaps for iron and zinc in infancy (6-12 mo) 1As currently formulated, dont fill the gaps for iron and zinc in infancy (6-12 mo) 1 Micronutrient fortified sprinkles and spreads have shown promise in filling some micronutrient gapsMicronutrient fortified sprinkles and spreads have shown promise in filling some micronutrient gaps New efforts underway to define standards for micronutrient content of both foods specially fortified for IYC and for micronutrient powders and spreads 2New efforts underway to define standards for micronutrient content of both foods specially fortified for IYC and for micronutrient powders and spreads 2 Fortified commodities have a role to playFortified commodities have a role to play As currently formulated, dont fill the gaps for iron and zinc in infancy (6-12 mo) 1As currently formulated, dont fill the gaps for iron and zinc in infancy (6-12 mo) 1 Micronutrient fortified sprinkles and spreads have shown promise in filling some micronutrient gapsMicronutrient fortified sprinkles and spreads have shown promise in filling some micronutrient gaps New efforts underway to define standards for micronutrient content of both foods specially fortified for IYC and for micronutrient powders and spreads 2New efforts underway to define standards for micronutrient content of both foods specially fortified for IYC and for micronutrient powders and spreads 2 1 Ruel et al, GAIN. Proposed products and formulations for GAINs IYCN Program support, draft, February, GAIN. Proposed products and formulations for GAINs IYCN Program support, draft, February, 2007

Summing up… Poverty is one of the key determinants of malnutrition.Poverty is one of the key determinants of malnutrition. Poor people have limited access to micronutrient rich foods (non-grain component of total food expenditure).Poor people have limited access to micronutrient rich foods (non-grain component of total food expenditure). Chronic malnutrition develops very early, in some places, even before birth.Chronic malnutrition develops very early, in some places, even before birth.

Summing up…(cont.) Pregnancy and the period up to 2 years of age is a critical period for addressing chronic malnutrition.Pregnancy and the period up to 2 years of age is a critical period for addressing chronic malnutrition. A combination of programmatic strategies supporting access and availability of adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants living in poverty show promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world.A combination of programmatic strategies supporting access and availability of adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants living in poverty show promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world. Pregnancy and the period up to 2 years of age is a critical period for addressing chronic malnutrition.Pregnancy and the period up to 2 years of age is a critical period for addressing chronic malnutrition. A combination of programmatic strategies supporting access and availability of adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants living in poverty show promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world.A combination of programmatic strategies supporting access and availability of adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants living in poverty show promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world.