1. Lancet Series Update 2013 By Monica Muti
National Nutrition Technical Update Meeting
05-06 August 2013
Kadoma Hotel

2. Maternal and Child Nutrition 1:
Maternal and child undernutrition and overweight in low-income and middle-income countries

3. Aim of this paper
Assess the prevalence of nutritional conditions and their health and development consequences
To reassess the problems of maternal and child under-nutrition
To examine the growing problems of overweight and obesity for women and children and their consequences in low-income and middle-income countries (LMICs).
To assess national progress in nutrition programmes
To assess international actions consistent with previous recommendations

4. Framework
shows the means to optimum fetal and child growth and development, rather than the determinants of undernutrition
framework shows the dietary, behavioural, and health determinants of optimum nutrition, growth, and development
and how they are affected by underlying food security, caregiving resources, and environmental conditions, which are in turn shaped by economic and social conditions, national and global contexts, resources, and governance.
This Series examines how these determinants can be changed to enhance growth and development.

5. Framework for action to achieve optimum fetal and child nutrition and development

6. Adolescent Nutrition 1.2 billion adolescents (12-19years) in the world
90% live in low to middle income countries(LMIC)
Potential for catch up growth of stunted children??
Adolescent fertility three times higher in LMICs than in high-income countries.
Pregnancies in adolescents
higher risk of complications and mortality in mothers and children
poorer birth outcomes
slow and stunt a girl’s growth.
In some countries, as many as half of adolescents are stunted, 11% thin, 5% obese
High prevalence of anaemia

7. Maternal Nutrition
Prevalence of over weight (BMI ≥25 kg/m2) and obesity (BMI ≥30 kg/m2)
rising in all regions (more than 40% in Africa by 2008)
Obese pregnant women
four times more likely to develop gestational diabetes mellitus and
two times more likely to develop pre-eclampsia
During labour and delivery, maternal obesity is associated with
maternal death, haemorrhage, caesarean delivery, or infection;29–31 and a higher risk of neonatal and infant death
MUAC in pregnancy inversely associated with all cause mortality up to 42 days postpartum(one study)
Inverse association between maternal height and the risk of dystocia (difficult labour)

8. Anaemia and Iron
Among pregnant women with anaemia at baseline, iron supplementation led to a 10・2 g/L increase in haemoglobin (8・0 g/L in children)
20% reduction in the risk of low birth weight associated with antenatal supplementation with iron alone or combined with folic acid
Risk of death of children younger than 5 years reduced by 34% when the mother consumed any iron-folic acid supplements (Dibley et.al)
protective effect greatest for deaths on the first day of life

9. Vitamin A and Zinc
Prevalence of night blindness in pregnant women estimated to be 7・8%
night blindness known to be associated with a four-times higher odds of low serum retinol
Maternal night blindness associated with increased low birth weight and infant mortality
trials of vitamin A in pregnancy not showed significant effects on these outcomes
17% of the world’s population at risk of zinc deficiency
Based on analysis of national diets

10. Iodine and Folate
28.5% of the world’s population estimated to be iodine deficient
Review of the effects of iodine supplementation in deficient populations showed a small increase in birth weight
Substantial proportion of neural tube defects related to inadequate consumption of folic acid around the time of conception
five trials of folic acid (a synthetic form of folate) supplementation identified a 72% reduction in the risk of neural tube defects

11. Childhood Nutrition
Stunting - decreased from an estimated 40% in 1990, to an estimated 26% in 2011
Underweight - 16% ( 36% decreased from 1990)
Wasting – 8% (11% decrease from 1990)
Suboptimum growth shown to increase the risk of death from infectious diseases in childhood
Stunting and underweight with highest proportion of attributed child deaths (14%)
Overweight – 4% to 11% in Africa (projected to reach 11% in 2025)
strong risk factor for adult obesity and its consequences

12. Determinants of childhood stunting and overweight
Promotion of appropriate complementary feeding practices reduces the incidence of stunting
Diarrhoea is the most important infectious disease determinant of stunting of linear growth
25% of stunting attributed to five previous episodes of diarrhoea
Optimum growth in the first 1000 days of life essential for prevention of overweight
rapid weight gains in the first 1000 days strongly associated with adult lean mass

13. Conclusion to paper 1
Evidence supports focus on pregnancy and the first 2 years of life
More emphasis to the nutritional conditions
in adolescence,
at the time of conception, and
during pregnancy, as important for maternal health and survival, fetal growth and sub sequent early childhood survival, growth, and development.
Fetal growth restriction and poor growth early in infancy now recognised as important determinants of neonatal and infant mortality, stunting, and overweight and obesity in older children and adults
Preventive efforts should continue to focus on the 1000 days
Therapeutic efforts should continue to target severe wasting.

14. Maternal and Child Nutrition 2
Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

15. Background
Update of interventions to address under-nutrition and micronutrient deficiencies in women and children
Current total of deaths in children younger than 5 years can be reduced by 15% if populations can access ten evidence-based nutrition interventions at 90% coverage
About a fifth of the existing burden of stunting can be averted using these approaches, if access is improved in this way

16. Interventions to address adolescent health and nutrition
Reproductive health and family planning interventions
to reduce unwanted pregnancies
to optimise age at first pregnancy
Community and school-based education platforms
To address micronutrient deficiencies
To address emerging issues of overweight and obesity in adolescents

17. Interventions in women of reproductive age and during pregnancy
Folic acid supplementation
Review of folic acid supplementation during pregnancy
Increase in mean birth weight
79% reduction in incidence of megaloblastic anaemia
Logistical challenges in reaching women of reproductive age in the peri-conceptual period
Fortification of cereals and other foods a possible solution

18. Interventions in women of reproductive age and during pregnancy
Iron or iron and folic acid supplementation
WHO recommends daily iron supplementation during pregnancy as part of the standard of care in populations at risk of iron deficiency
Maternal multiple micronutrient supplementation
Reduction in LBW, SGA, small effect on preterm births
Potential for replacement of iron-folate supplements in pregnancy in populations at risk
Maternal calcium supplementation
shown to reduce maternal hypertensive disorders and preterm birth

19. Interventions in women of reproductive age and during pregnancy
Maternal iodine supplementation or fortification
Iodised salt use the most cost-effective way to avert deficiency
Addressing maternal wasting and food insecurity with balanced energy and protein supplementation
Balanced energy protein supplementation, providing about 25% of the total energy supplement as protein
Leads to increased birth weight by 73g and reduced risk of SGA by 34%

20. Nutrition interventions in neonates
Delayed cord clamping
Significant increase in newborn haemoglobin
Higher serum ferritin concentration at 6 months of age
Neonatal vitamin K administration
Neonatal vitamin A supplementation
Additional data needed before developing recommendations
Kangaroo mother care

21. Nutrition interventions in infants and children
Promotion of breastfeeding and supportive strategies
Early initiation, EBF to six months, continued BF to 24months or more - global progress both uneven and suboptimal
Education and counselling interventions important
More needs to be done to assess innovations and strategies to promote breast feeding in working women
Promotion of dietary diversity and complementary feeding

22. Nutrition interventions in infants and children
Vitamin A supplementation in children
continues to be an effective intervention in children aged 6–59 months in populations at risk of vitamin A deficiency
Iron supplementation in infants and children
Multiple micronutrient supplementation in children
Preventive zinc supplementation in children

23. Disease prevention and management
Inpatient treatment for children with complicated SAM
Community-based care for uncomplicated SAM
programmatic evidence supports use of RUTF for community-based treatment

24. Ten nutrition interventions for scaling up
Peri-conceptional folic acid supplementation or fortification
Maternal balanced energy protein supplementation
Maternal calcium supplementation
Multiple micronutrient supplementation in pregnancy
Promotion of breast feeding
Appropriate complementary feeding
Vitamin A in children 6–59 months of age
Preventive zinc supplementation in children 6–59 months of age
Management of SAM
Management of MAM

25. Conclusion Scaling up to 90% coverage associated with
15% reduction in under five mortality
Little effect on maternal mortality
Mean 20.3% (range 11・1–28・9) reduction in stunting
61・4% (35・7–72) reduction in severe wasting
Interventions with the largest potential effect on mortality in children younger than 5 years:
Management of SAM
Preventive zinc supplementation
Promotion of breastfeeding