1. Public Nutrition: Policies and Programs INHL 613 Tues – Thurs 3.00 – 4.40 12 Jan – 2 Mar 2010

2. Course. 1.Principles and introduction 2.Community-based Health and Nutrition Programs 3.Micronutrient Programs 4.National planning exercise.

3. 1.What are nutrition and public nutrition? 2.Consequences of malnutrition (hence: why bother?) 3.Causes of malnutrition to tackle (what to do about it?) 4.Brief epidemiology 5.Context and program principles Introduction

5. What does ‘nutrition’ cover? Consequences … For children: Health (direct and risk factor – see DALYs) Survival/mortality risk Intellectual development, educational result Nutritional status (micronutrients, growth – affects future earnings) For women: Health (direct and risk) Reproduction, intra-uterine development in pregnancy Nutritional status (especially anemia) For all: Health Activity, productive and discretionary Freedom from hunger These apply to undernutrition and obesity: we deal mainly with undernutrition.

6. ‘Public Nutrition…’

8. Mortality risk

9. J Nutr.124:2106S-2122S, 1994

10. Source: Lancet nutrition series #1, 2008

11. 15-20 years later Maternal and child undernutrition: consequences for adult health and human capital Source: Lancet nutrition series #2, 2008

14. Source: 2 nd and 6 th UN World Nutrition Report/Tulane.

17. ‘Nutrition…’

18. What does ‘nutrition’ cover? Causes and interventions. See various frameworks, e.g. UNICEF – proximal causes: Poverty and food security Health environment, access to services Care … (Converse of hunger, sickness, and neglect) These interact and have important feedback loops (e.g. see malnutrition- infection spiral). More distal causes often are contextual rather than intervenable upon. Time and biology are crucial – intra-uterine development (even at conception) has major influence (even on next generation). Context, and program interventions: context determines whether interventions are effective; often cannot be quickly changed. Single interventions are of well-known effectiveness, but they also importantly interact and have feedback loops. Issues are HOW to sustainably support them, and combine them.

24. Source: Lancet nutrition series #3, 2008

27. Epidemiology

30. Source: Lancet nutrition series #1, 2008

34. Context

42. Program Intervention and Context A. In unfavourable context, program intervention for the individual has limited effect

43. Program Intervention and Context B. In better context, program intervention for the individual has much more effect

44. Program Intervention and Context C. In highly supportive context, improvement is endogenous and program intervention gives additional effect

45. Figure 23

48. Programs to improve nutrition … (meaning all those consequences for children, women, society, outlined earlier) What? How? Depends on …

51. Source: Lancet nutrition series #3, 2008

53. Programs: how? Multiple (complementary) components within: CHNPS (community-based health and nutrition programs Service delivery (including IMCI) Central/vertical programs (e.g. fortification) Child Health Days