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Evidence Based Interventions for Improving Maternal and Child Nutrition: What Can be Done and at What Cost? Zulfiqar A Bhutta 1,2, Jai K Das 1, Arjumand.

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Presentation on theme: "Evidence Based Interventions for Improving Maternal and Child Nutrition: What Can be Done and at What Cost? Zulfiqar A Bhutta 1,2, Jai K Das 1, Arjumand."— Presentation transcript:

1 Evidence Based Interventions for Improving Maternal and Child Nutrition: What Can be Done and at What Cost? Zulfiqar A Bhutta 1,2, Jai K Das 1, Arjumand Rizvi 1, Michelle Gaffey 2, Neff Walker 3, Sue Horton 4, Patrick Webb 5, Anna Lartey 6, 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? 2

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 3

4 Interventions Across the Lifecycle 4

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 MMN 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 5

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 6

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 7

8 Breast Feeding Promotion-Effects on breast feeding rates OutcomeEstimates EBF at Day 143% RR: 1.43 ( ) increase EBF at 4-6 weeks30% (RR: 1.30, 95% CI: ) increase EBF at 6 month90% (RR: 1.90, 95% CI: ) increase Effects on exclusive breastfeeding rates Effects on NOT breastfeeding OutcomeEstimates Not breast feeding at Day 132% (RR: 0.68, 95% CI: ) decrease Not Breast feeding at 1 month30% (RR: 0.70, 95% CI: ) decrease Not breast feeding at 6 months18% (RR: 0.82, 95% CI: ) decrease

9 Behavior Change Communication for Improved Complementary Feeding Outcome Estimates Complementary Feeding education alone in food secure populations WAZSMD: 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 WAZSMD: 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 HAZSMD: 0·25 (95% CI 0·09, 0·42) Stunting RR: 0·68 (95% CI 0·60, 0·76) WAZ 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 WAZSMD: 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 HAZSMD: 0·25 (95% CI 0·09, 0·42) Stunting RR: 0·68 (95% CI 0·60, 0·76) WAZ SMD: 0·26 (95% CI 0·12, 0·41) Complementary food provision with education in food insecure populations HAZ SMD: 0.39 (95% CI: 0.05, 0.73) WAZ SMD: 0·26 (95% CI 0·04–0·48) underweightRR: 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 13

14 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 Modeling the Impact of Interventions: Whats New? 14

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

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

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 %) 17

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

19 Packages of Nutrition Interventions 19 Maternal multiple micronutrient supplements to all Calcium supplementation to mothers at-risk of low intake 3 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 Nutrition interventions Number of lives saved Cost per life-year saved Optimum maternal nutrition during pregnancy102,000 (49, ,000) $571 (398-1,191) Infant and young child feeding221,000 (135, ,000) $175 ( ) Micronutrient supplementation in children at risk 145,000 (30, ,000) $159 ( ) Management of acute malnutrition435,000 (285, ,000) $125 ( ) 20

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 1.Multiple micronutrient supplementation in pregnancy 2.Promotion of breastfeeding 3.Promotion of appropriate complementary feeding 4.Vitamin A supplementation 5.Preventive zinc supplementation 6.Treatment of diarrhoea with zinc 7.Recognition and management of severe acute malnutrition

25 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 worlds 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 26

27 Total Additional Annual Cost of Achieving 90% Coverage with Nutrition Interventions Nutrition interventionsCost 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. 27

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 28


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