1. What Can be Done and at What Cost?
Evidence Based Interventions for Improving Maternal and Child Nutrition:
What Can be Done and at What Cost?
Zulfiqar A Bhutta1,2, Jai K Das1, Arjumand Rizvi1, Michelle Gaffey2, Neff Walker3, Sue Horton4, Patrick Webb5, Anna Lartey6, Robert E Black for Lancet Maternal and Child Nutrition & Interventions Review Groups
1 The Aga Khan University and Medical Center, Karachi, Pakistan
2 Hospital for Sick Children (Sick Kids), Toronto , Canada
3 Johns Hopkins University, Baltimore, USA
4 University of Waterloo, Canada
5 Tufts University, Boston, USA
6 University of Ghana, Ghana

2. Nutrition-Specific Interventions and Programs: How can they Help Accelerate Progress in Improving Maternal and Child Nutrition?

3. Furthering the Evidence Base to Improve Maternal and Child Nutrition
Since 2008 Lancet Series, many nutrition interventions have been successfully implemented at scale, and the evidence base for effective interventions and delivery strategies has grown; coverage rates for other interventions are either poor or non-existent
The evidence base for nutrition specific and sensitive interventions was updated & enhanced
Ten nutrition-specific interventions across the life cycle to address undernutrition and micronutrient deficiencies in women and children were modelled to assess impact and cost of scaling up

4. Interventions Across the Lifecycle

5. Nutrition Interventions Reviewed
Women of reproductive age and pregnancy
Folic acid supplementation
Iron and iron-folate supplementation
MMN supplementation
Calcium supplementation
Iodine through iodisation of salt
Maternal supplementation with balanced energy protein
Neonates
Delayed cord clamping
Neonatal vitamin K administration
Vitamin A supplementation
Kangaroo mother care and promotion of breastfeeding
Infants and children
Complementary feeding promotion (6-24 months)
Preventive vitamin A supplementation (6 months – 5 years)
Iron supplementation
Zinc supplementation
Disease prevention and management
WASH interventions
Maternal deworming
Deworming in children
Feeding practices in diarrhoea
Zinc therapy for diarrhoea
IPTp/ITN for malaria in pregnancy
Malaria prophylaxis in children

6. Delivery Platforms Reviewed
Community delivery platforms for nutrition education and promotion
Improve rates of facility births by 28%
Doubling of initiation of breastfeeding within 1 h and EBF
Substantial potential to improve the uptake of child health and nutrition outcomes among difficult to reach populations
Reduction of financial barriers
Policy strategies to ameliorate poverty, reduce financial barriers, and improve population health
Promote increased coverage of child health interventions
Pronounced effects achieved by those that directly removed user fees for access to health services
Integrated Management of Childhood Illness (IMCI)
Includes both curative and preventive interventions at health facilities and at home
Various benefits in health services, quality, mortality reduction, and health-care cost savings
Significant increase in EBF and comparatively faster reduction in the prevalence of stunting

7. Delivery Platforms Reviewed
Fortification strategies
MMN: Increase in haemoglobin concentrations and reduced risk of anaemia by 57%
Iron fortification - 41% reduction in anaemia and 52% reduction in iron deficiency
Vitamin D fortification increased serum 25-OH D concentration
Zinc fortification- higher serum and erythrocyte zinc concentration and lower serum copper
Child health days
Introduced in weak health systems to rapidly enhance coverage of essential child survival interventions
Promote increased coverage than stand alone campaigns
Overall equity effect of these approaches are uncertain and further studies are needed
School-based delivery platforms
Two tier- Improve attendance and health
Improve school attendance by 4-6 days annually and weight gains 0.39 kg over 11 months and 0.71 kg over 19 months
Evidence scarce- Enormous opportunity

8. Breast Feeding Promotion-Effects on breast feeding rates
Effects on exclusive breastfeeding rates
Outcome
Estimates
EBF at Day 1
43% RR: 1.43 ( ) increase
EBF at 4-6 weeks
30% (RR: 1.30, 95% CI: ) increase
EBF at 6 month
90% (RR: 1.90, 95% CI: ) increase
Effects on NOT breastfeeding
Outcome
Estimates
Not breast feeding at Day 1
32% (RR: 0.68, 95% CI: ) decrease
Not Breast feeding at 1 month
30% (RR: 0.70, 95% CI: ) decrease
Not breast feeding at 6 months
18% (RR: 0.82, 95% CI: ) decrease

9. Behavior Change Communication for Improved Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)

10. Behavior Change Communication for Improved Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Complementary Feeding education alone in food insecure populations
HAZ
SMD: 0·25 (95% CI 0·09, 0·42)
Stunting
RR: 0·68 (95% CI 0·60, 0·76)
SMD: 0·26 (95% CI 0·12, 0·41)

11. Behavior Change Communication for Improved Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Complementary Feeding education alone in food insecure populations
HAZ
SMD: 0·25 (95% CI 0·09, 0·42)
Stunting
RR: 0·68 (95% CI 0·60, 0·76)
SMD: 0·26 (95% CI 0·12, 0·41)
Complementary food provision with education in food insecure populations
SMD: 0.39 (95% CI: 0.05, 0.73)
SMD: 0·26 (95% CI 0·04–0·48)
underweight
RR: 0.35 (95% CI: 0.16, 0.77)

12. Micronutrient interventions in childhood
Vitamin A Supplementation: Reduces all-cause mortality (RR 0·76, 95% CI 0·69–0·83), diarrhoea-related mortality (RR 0·72, 95% CI 0·57–0·91), incidence of diarrhoea (RR 0·85, 95% CI 0·82–0·87) and incidence of measles (RR 0·50, 95% CI 0·37–0·67)
Preventive Zinc Supplementation: Reduces incidence of diarrhoea RR: 0.87 (95% CI 81–94) and pneumonia RR: 0.81 (95% CI 0.73–0.90) and improves mean height gain by 0·37 cm (SD 0·25)
Iron Supplementation: Reduces anaemia (RR 0·51, 95% CI 0·37–0·72), increases haemoglobin concentration (MD 5·20 g/L, 95% CI 2·51–7·88) and ferritin concentration (MD 14·17 mcg/L, 95% CI 3·53–24·81). Developmental benefits mainly in school age children.
Micronutrient Powders: Reduce anaemia (RR 0·66, 95% CI 0·57–0·77), retinol deficiency (RR 0·79, 95% CI 0·64–0·98) and improve haemoglobin concentrations (SMD 0·98, 95% CI 0·55–1·40). Further evaluation of safety needed when used at scale

13. LiST modeling effects on mortality for 34 high burden countries: revised model

14. Modeling the Impact of Interventions: What’s New?
Major component remains a cohort model, following children from birth to 36 months, with stunting and death as outcomes. Wasting is also included in the model
Main outcomes (mortality and stunting impact) reported across the under 5 period as opposed to point impact at 36 months of age
Target coverage 90% (compared to 99% in 2008) in 34 countries with maximum burden
Explain that figure shows the sort of information generated by the model. Go through what it shows – what happens to children between birth and 36 months of age – so by 36 months of age about 9% of children have died and of those who survive over half (58%) are stunted. 14

15. Countries With High Burden of Malnutrition
These 34 countries account for 90% of the global burden of malnutrition

16. Effect of Scale-up Interventions on Cause-specific Deaths

17. Impacts
Mortality in children younger than 5 years could be reduced by 15% (range 9-19%)
35% (19-43) reduction in diarrhoea-specific mortality
29% (16-37) reduction in pneumonia-specific mortality
39% (23-47) reduction in measles-specific mortality
Reduced deaths due to asphyxia and congenital anomalies
Little effect on maternal mortality
Stunting overall reduced by at least 20.3% (range %)
Severe wasting reduced overall by 61.4% (range %)

18. Effect of Scale-up Interventions on Deaths in Children Younger than 5 Years

19. Packages of Nutrition Interventions
Maternal multiple micronutrient supplements to all
Calcium supplementation to mothers at-risk of low intake3
Maternal balanced energy protein supplements as needed
Universal salt iodization
Optimal maternal nutrition during pregnancy
Promotion of early, exclusive breastfeeding for 6 months; continued breastfeeding until 24 months
Appropriate complementary feeding education in food secure populations and additional complementary food supplements in food insecure populations
Infant and young child feeding
Vitamin A supplementation between 6-59 months age
Preventive zinc supplements between months of age
Micronutrient supplementation in children at risk
Supplementary feeding for moderate acute malnutrition
Management of severe acute malnutrition
Management of acute malnutrition

20. Effect of Packages of Nutrition Interventions at 90% Coverage
Number of lives saved
Cost per life-year saved
Optimum maternal nutrition during pregnancy
102,000
(49, ,000)
$571
(398-1,191)
Infant and young child feeding
221,000
(135, ,000)
$175
( )
Micronutrient supplementation in children at risk
145,000
(30, ,000)
$159
( )
Management of acute malnutrition
435,000
(285, ,000)
$125
( )

21. Can community based nutrition programs reach the poor?

22. All Community Platforms
Maternal mortality (RR 0.81; 95% CI: 0.59 to 1.11)
Maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92)
Neonatal deaths (RR 0.74; 95% CI 0.66 to 0.83)
Stillbirths (RR 0.79; 95% CI 0.70 to 0.90)
Perinatal mortality (RR 0.74; 95% CI 0.66 to 0.84)

23. All Community Platforms
Maternal mortality (RR 0.81; 95% CI: 0.59 to 1.11)
Maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92)
Neonatal deaths (RR 0.74; 95% CI 0.66 to 0.83)
Stillbirths (RR 0.79; 95% CI 0.70 to 0.90)
Perinatal mortality (RR 0.74; 95% CI 0.66 to 0.84)
Facility births (RR 1.28; 95% CI 1.04 to 1.59)
Breastfeeding rates 125% (RR 2.25; 95% CI 1.70 to 2.97)
Skilled care births (RR 1.59; 95% CI 0.64 to 3.95)
Iron/folate supplementation (RR 1.47; 95% CI 0.99 to 2.17).

24. Community based Interventions Modeled
Multiple micronutrient supplementation in pregnancy
Promotion of breastfeeding
Promotion of appropriate complementary feeding
Vitamin A supplementation
Preventive zinc supplementation
Treatment of diarrhoea with zinc
Recognition and management of severe acute malnutrition

25. Equity Analysis of Effect of Scale Up Nutrition Interventions

26. Potential Impact of Scaling Up 10 Proven Interventions
Continued investment in nutrition-specific interventions and delivery strategies to reach poor segments of the population at greatest risk can make a significant difference
If these 10 proven nutrition-specific interventions were scaled-up from current population coverage to 90%, we could:
Save an estimated 900,000 lives in 34 high burden countries (where 90% of the world’s stunted children live)
Reduce the number of children with stunted growth and development by 33 million
On top of existing trends, the WHA targets for 2025 are reachable

27. Nutrition interventions
Total Additional Annual Cost of Achieving 90% Coverage with Nutrition Interventions
Nutrition interventions
Cost
Salt iodisation
$68
Multiple micronutrient supplementation in pregnancy (includes iron-folate)
$472
Calcium supplementation in pregnancy
$1914
Energy-protein supplementation in pregnancy
$972
Vitamin A supplementation in childhood
$106
Zinc supplementation in childhood
$1182
Breastfeeding promotion
$653
Complementary feeding education
$269
Complementary feeding supplementation
$1359
SAM management
$2563
Total
$9559
Data are 2010 international dollars, millions.

28. Paper 2 Key Messages
Promising interventions exist to improve maternal nutrition and reduce fetal growth restriction and small-for-gestational age (SGA) births in appropriate settings in developing countries, if scaled up A set of 10 evidence-based interventions if implemented at scale can save at least 15% of under 5 child deaths (i.e. 1 million lives saved) and avert a fifth of all stunting Delivery strategies exist to especially target undernutrition and impact child mortality among the poorest The costs for scaling up these nutrition specific interventions globally is $9.6 billion, affordable given the gains A clear need and opportunity exists to introduce promising evidence-based interventions in the preconception period and adolescents and also address the impact on long-term neurodevelopmental outcomes