Landscape of Nutrition: the 2008 Lancet Series on Maternal and Child Nutrition Reynaldo Martorell Hubert Department of Global Health, Rollins School of Public Health Emory University Atlanta, GA. USA

The Causes of Malnutrition (adapted from UNICEF) Malnutrition and Death Poor diets Infection Insufficient access to FOOD Inadequate child CARE Poor environment and inadequate HEALTH services BASIC CAUSES Individual Family Society

About the Series

Gestation and the first 2 years of life represent a window of vulnerability for human development High nutritional requirements Rapid growth and development Greater susceptibility to infections Fully dependent on others for care

Dietary Recommendation for Iron (mg/kg/day) from high quality diets + + Dietary Reference Intakes. IOM, Infant, 9 months Adult Male

Age (months) Z Mean Z-scores for height-for-age relative to the new WHO standards for Peru, 2000

Age (months) Z Mean Z-scores for height-for-age relative to the new WHO standards for Peru, 2000

Human brain development Original: Thompson, 2001; taken from Grantham-McGregor, 2007

Brain development in early life Brain development early life is dramatic and depends on the interaction between genes and how the child experiences the world. Nutrition, child care and stimulation in early life effect directly the wiring of the brain and this has a lasting effect on learning capacity, behavior and the ability to regulate emotions. + Reversing the Real Brain Drain. Early Years Study. April 1999.

PAPER 1 High Prevalence of IUGR, Stunting and Severe Wasting in Children Under 5 ( Black et al, 2008)

Deaths % of deaths in children < 5 y Stunting1,491, % Wasting449,1604.4% IUGR337,0473.3% ↓ Vitamin A667,7716.5% ↓ Zinc453,2074.4% ↓ Iron ,8540.2% ↓ Iodine3, % Total ++ 2,800,00028% Total + 2,184, % + Takes into account the joint distribution between stunting and wasting. ++ Takes into account the joint distribution among nutritional problems. +++ Responsible for 115,000 maternal deaths per year or 20% of maternal mortality Mortality in children < 5 y attributable to nutritional problems Total 1,145, %

PAPER 1 Suboptimal Breastfeeding Suboptimal breastfeeding accounts for 1.4 million deaths annually

Mortality statistics do not capture long term effects on human capital

Maternal and child undernutrition (paper 2) Consequences for adult health and human capital Victora CG, Adair L, Fall CHD, Hallal PC, Martorell R, Richter L, Sachdev HPS

a review of published data linking maternal and child undernutrition with adult outcomes a combined analysis of new data from 5 developing countries where people have been monitored from birth to adulthood

Guatemala Pelotas Soweto Delhi Cebu

Damage Suffered in Early Life Leads to Permanent Impairment PAPER 2

Rapid Weight Gain After Being Undernourished Increases Chronic Disease Risk as Adults PAPER 2

Years of increased schooling associated with a standard deviation shift in birth weight and conditional weight gain (0-24 and 24-48m) in 5 cohort studies, after control for confounding One standard deviation (z) of birth weight =0.5 kg weight gain (0-24m) = 0.7 kg weight gain (24-48m) = 0.9 kg Martorell et al., under review (N.S.) Adjusted for SES and maternal education

Lancet Series on Maternal and Child Undernutrition: paper 3 What works? Interventions to affect maternal and child undernutrition and survival globally. Bhutta et al, The Lancet, 2008

Evidence-Based Interventions PAPER 3

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

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

Paper 3 Key Messages PAPER 3

Meta-analyses of micronutrients and birthweight (Martorell in press) Composition # of studies Unweighted birthweight differences (g) Unweighted effect sizes 95% C.I.P Iron vs. Placebo MM vs. Iron < MM vs. Placebo 0????

OutcomeRisk ratios (95% CI)Reduction Mortality 0.91 (0.82 – 0.99)9% Diarrhea 0.86 (0.79 – 0.93)14% Severe diarrhea /dysentery 0.85 (0.75 – 0.95)15% Persistent diarrhea 0.75 (0.57 – 0.98)25% Pneumonia 0.80 (0.70 – 0.92)20% Meta-analyses of the preventive impact of zinc supplementation on morbidity and mortality ( Bhutta et al, 2008)

Meta-analysis of the impact of zinc supplementation on linear growth in children (Bhutta et al, 2008) No new analyses about zinc and growth were carried out for the Lancet series. The results published by Brown, Peerson, Rivera and Allen (2002) were accepted for the series. These authors found a mean effect size on height changes of 0.35 Z (0.19 – 0.51) in an analyses that included children of all ages. Zinc supplementation features as one of the most potent measures to reduce stunting.

Studies included by Brown et al ( 2002) Effect size 0.26 Z (95% CI: 0.08, 0.43 ) Studies not included by Brown et al ( 2002) Effect size 0.02 Z (95% CI: -0.07, 0.11 ) All available studies 0.07 Z (95% CI: -0.03, 0.17) Effect of zinc on growth in height in children less than 5 y (Ramakrishnan, Nguyen and Martorell, 2009)

Stratified analyses of zinc effects on growth in height in children less than 5 y (Ramakrishnan, Nguyen and Martorell, 2009) Population not stunted at baseline; mean HAZ ≥ -2 Population stunted at baseline; mean HAZ ≤ -2

Intervention Number of studies Type of population Effect size Height/age (Z) + Education/communication, without food or $ transfers 3Food secure ( ) Food or $ transfers, with or without education/communication 7Food insecure 0.41 ( ) Education /communication, without food or $ transfers 0Food insecure ?? Interventions to improve complementary feeding (Bhutta et al, 2008) + Weighted mean difference and 95% C.I. ++ More than 1 US$ per day per capita

From Bhutta et al, 2008

Stunting Poverty

Y Chen and LA Zhou, The long-term health and economic consequences of the 1959–1961 famine in China. J Health Econ, 26: , million people died in the famine in China (Great Leap Forward) Survivors born in (exposed early in life) were compared to cohorts born before or after the famine. Famine exposure in early life was associated with a reduction in: –Adult height, 3 cm –Annual per capita income, 33% lower (my estimate)

INCAP longitudinal study, Community-randomized supplementation trial (2 large and 2 small villages). Two villages (1 large, 1 small) received Atole, a nutritious supplement made from Incaparina, milk and sugar, and two (1 large, 1 small) received Fresco, a less nutritive drink. Martorell R, Habicht J-P, Rivera JA. History and design of the INCAP longitudinal study ( ) and its follow-up ( ). Journal of Nutrition 125(Suppl. 4S):1027S-1041S, 1995.

Impact on total nutrient intakes and on growth Total diets of young children from Atole villages were greater by 9 g of protein, 100 kcal/day and in micronutrients when compared to diets of children from Fresco villages. Length was increased by 2.5 cm in atole vs. fresco but only in the first three years of life.

Difference in length at 3 years of age between children (n = 453) exposed to supplement during their lives and those measured at baseline: village level analysis Large Small LargeSmall AtoleFresco cm Villages t-test = p <.005 (2-tail, df = 2)

Econometric analysis of exposure to improved nutrition from 0-3 years of age on education (n = 1469) + Schooling: Effects found in women only -- Improved by 1.2 years Cognition: Effects found in men and women –Improved Raven scores by 8% ++ Reading: Effects found in men and women –Improved scores by 17% Maluccio, Hoddinott, Behrman, Martorell, Quisumbing & Stein. The Impact of Nutrition during Early Childhood on Education among Guatemalan Adults. The Economic Journal, Raven Progressive Matrices +++ Inter-American Reading Series

Long terms effects of a nutrition intervention carried out in Guatemala in _______________________________ Hoddinott, Maluccio, Behrman, Flores and Martorell. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults (The Lancet, 2008). Improved nutrition before, but not after 3 years of age, increased wages in men by 46% and annual incomes by $914

The Lancet series did not consider implementation issues in detail nor costs of scaling up programs

Letter to the editor of Lancet entitled “Delivery Sciences in Nutrition”: Meera Shekar y 17 others (May, 2008) Seeks to understand the implementation and cost effectiveness at scale The letter proposes that we know more about “Discovery” than “Delivery Sciences” and analyzes the causes of lack of capacity in Delivery Sciences –Lack of explicit training in leading universities –Near absence of research on delivery sciences, including operational research –What little is done is of poor quality –Scarce funding for research on delivery sciences –Reluctance of journals to publish such research