1. Strategies for Addressing Chronic Malnutrition in Infants and Young Children Mary Arimond, IFPRI and Judy Canahuati, USAID Mary Arimond, IFPRI and Judy Canahuati, USAID IFAC, Tuesday, April 15 Photo: CARE USA

2. OutlineOutline Window of opportunity: conception- 24 monthsWindow of opportunity: conception- 24 months Why does growth falter?Why does growth falter? Prevention vs. curePrevention vs. cure Guiding Principles for feedingGuiding Principles for feeding “Problem” nutrients; nutrient gaps“Problem” nutrients; nutrient gaps Options for filling the gapsOptions for filling the gaps Indicators for measuring progressIndicators for measuring progress Window of opportunity: conception- 24 monthsWindow of opportunity: conception- 24 months Why does growth falter?Why does growth falter? Prevention vs. curePrevention vs. cure Guiding Principles for feedingGuiding Principles for feeding “Problem” nutrients; nutrient gaps“Problem” nutrients; nutrient gaps Options for filling the gapsOptions for filling the gaps Indicators for measuring progressIndicators for measuring progress

3. Chronic malnutrition begins early* *Lancet series on Nutrition 2008 www.GlobalNutritionSeries.org, www.GlobalNutritionSeries.org WB Repositioning Nutrition as Central to Development, 2006 http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf *Lancet series on Nutrition 2008 www.GlobalNutritionSeries.org, www.GlobalNutritionSeries.org WB Repositioning Nutrition as Central to Development, 2006 http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf

4. Period of most rapid growth and vulnerability to growth faltering Period of most rapid growth and vulnerability to growth faltering Shrimpton et al. 2001 Age (months)Age (months)

5. 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 Annual change in length by age, with consumption of an additional 100 kcal/d of high-energy/protein supplement Age

6. 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

7. 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

8. 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 child’s fluid needs with safe fluids, including clean waterMeet child’s 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 child’s fluid needs with safe fluids, including clean waterMeet child’s 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…….

9. 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

10. “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

11. 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

12. Filling the gap Fortified commodities have a role to playFortified commodities have a role to play As currently formulated, don’t fill the gaps for iron and zinc in infancy (6-12 mo) 1As currently formulated, don’t 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 2New efforts underway to define standards for micronutrient content of both foods specially fortified for IYC and for micronutrient powders 2 Fortified commodities have a role to playFortified commodities have a role to play As currently formulated, don’t fill the gaps for iron and zinc in infancy (6-12 mo) 1As currently formulated, don’t 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 2New efforts underway to define standards for micronutrient content of both foods specially fortified for IYC and for micronutrient powders 2 1 Ruel et al, 2004 2 GAIN. Proposed products and formulations for GAIN’s IYCN Program support, draft, February, 2007 2 GAIN. Proposed products and formulations for GAIN’s IYCN Program support, draft, February, 2007

13. How can we measure progress? Using framework of Guiding Principles…Using framework of Guiding Principles… Multi-year collaborative project to develop indicators for quality of infant and young child feedingMulti-year collaborative project to develop indicators for quality of infant and young child feeding New indicators to be published by WHO and partners (IFPRI, UC Davis, FANTA Project) in 2008*New indicators to be published by WHO and partners (IFPRI, UC Davis, FANTA Project) in 2008* Using framework of Guiding Principles…Using framework of Guiding Principles… Multi-year collaborative project to develop indicators for quality of infant and young child feedingMulti-year collaborative project to develop indicators for quality of infant and young child feeding New indicators to be published by WHO and partners (IFPRI, UC Davis, FANTA Project) in 2008*New indicators to be published by WHO and partners (IFPRI, UC Davis, FANTA Project) in 2008* *http://www.who.int/child_adolescent_health/documents/pdfs/iycf_indicators_for_peer_review.pdf

14. To sum up… Chronic malnutrition develops very early, in some places, even before birth.Chronic malnutrition develops very early, in some places, even before birth. 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 adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants are showing promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world.A combination of programmatic strategies supporting adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants are showing promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world. Chronic malnutrition develops very early, in some places, even before birth.Chronic malnutrition develops very early, in some places, even before birth. 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 adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants are showing promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world.A combination of programmatic strategies supporting adequate nutrition and care and a reconsideration of nutrient delivery for mothers and infants are showing promise in addressing chronic malnutrition, the most widespread type of malnutrition in the developing world.