Presentation on theme: "What Can be Done and at What Cost?"— Presentation transcript:
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 Groups1 The Aga Khan University and Medical Center, Karachi, Pakistan2 Hospital for Sick Children (Sick Kids), Toronto , Canada3 Johns Hopkins University, Baltimore, USA4 University of Waterloo, Canada5 Tufts University, Boston, USA6 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-existentThe evidence base for nutrition specific and sensitive interventions was updated & enhancedTen 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
5 Nutrition Interventions Reviewed Women of reproductive age and pregnancyFolic acid supplementationIron and iron-folate supplementationMMN supplementationCalcium supplementationIodine through iodisation of saltMaternal supplementation with balanced energy proteinNeonatesDelayed cord clampingNeonatal vitamin K administrationVitamin A supplementationKangaroo mother care and promotion of breastfeedingInfants and childrenComplementary feeding promotion (6-24 months)Preventive vitamin A supplementation (6 months – 5 years)Iron supplementationZinc supplementationDisease prevention and managementWASH interventionsMaternal dewormingDeworming in childrenFeeding practices in diarrhoeaZinc therapy for diarrhoeaIPTp/ITN for malaria in pregnancyMalaria prophylaxis in children
6 Delivery Platforms Reviewed Community delivery platforms for nutrition education and promotionImprove rates of facility births by 28%Doubling of initiation of breastfeeding within 1 h and EBFSubstantial potential to improve the uptake of child health and nutrition outcomes among difficult to reach populationsReduction of financial barriersPolicy strategies to ameliorate poverty, reduce financial barriers, and improve population healthPromote increased coverage of child health interventionsPronounced effects achieved by those that directly removed user fees for access to health servicesIntegrated Management of Childhood Illness (IMCI)Includes both curative and preventive interventions at health facilities and at homeVarious benefits in health services, quality, mortality reduction, and health-care cost savingsSignificant increase in EBF and comparatively faster reduction in the prevalence of stunting
7 Delivery Platforms Reviewed Fortification strategiesMMN: Increase in haemoglobin concentrations and reduced risk of anaemia by 57%Iron fortification - 41% reduction in anaemia and 52% reduction in iron deficiencyVitamin D fortification increased serum 25-OH D concentrationZinc fortification- higher serum and erythrocyte zinc concentration and lower serum copperChild health daysIntroduced in weak health systems to rapidly enhance coverage of essential child survival interventionsPromote increased coverage than stand alone campaignsOverall equity effect of these approaches are uncertain and further studies are neededSchool-based delivery platformsTwo tier- Improve attendance and healthImprove school attendance by 4-6 days annually and weight gains 0.39 kg over 11 months and 0.71 kg over 19 monthsEvidence scarce- Enormous opportunity
8 Breast Feeding Promotion-Effects on breast feeding rates Effects on exclusive breastfeeding ratesOutcomeEstimatesEBF at Day 143% RR: 1.43 ( ) increaseEBF at 4-6 weeks30% (RR: 1.30, 95% CI: ) increaseEBF at 6 month90% (RR: 1.90, 95% CI: ) increaseEffects on NOT breastfeedingOutcomeEstimatesNot breast feeding at Day 132% (RR: 0.68, 95% CI: ) decreaseNot Breast feeding at 1 month30% (RR: 0.70, 95% CI: ) decreaseNot breast feeding at 6 months18% (RR: 0.82, 95% CI: ) decrease
10 Behavior Change Communication for Improved Complementary Feeding OutcomeEstimatesComplementary Feeding education alone in food secure populationsWAZSMD: 0.20 (95% CI: 0.07, 0.33)Height GainSMD: 0.35 (95% CI: 0.08, 0.62)Weight GainSMD: 0.40 (95% CI: 0.02, 0.78)Complementary Feeding education alone in food insecure populationsHAZSMD: 0·25 (95% CI 0·09, 0·42)StuntingRR: 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 OutcomeEstimatesComplementary Feeding education alone in food secure populationsWAZSMD: 0.20 (95% CI: 0.07, 0.33)Height GainSMD: 0.35 (95% CI: 0.08, 0.62)Weight GainSMD: 0.40 (95% CI: 0.02, 0.78)Complementary Feeding education alone in food insecure populationsHAZSMD: 0·25 (95% CI 0·09, 0·42)StuntingRR: 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 populationsSMD: 0.39 (95% CI: 0.05, 0.73)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
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 modelMain outcomes (mortality and stunting impact) reported across the under 5 period as opposed to point impact at 36 months of ageTarget coverage 90% (compared to 99% in 2008) in 34 countries with maximum burdenExplain 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 ImpactsMortality in children younger than 5 years could be reduced by 15% (range 9-19%)35% (19-43) reduction in diarrhoea-specific mortality29% (16-37) reduction in pneumonia-specific mortality39% (23-47) reduction in measles-specific mortalityReduced deaths due to asphyxia and congenital anomaliesLittle effect on maternal mortalityStunting 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 allCalcium supplementation to mothers at-risk of low intake3Maternal balanced energy protein supplements as neededUniversal salt iodizationOptimal maternal nutrition during pregnancyPromotion of early, exclusive breastfeeding for 6 months; continued breastfeeding until 24 monthsAppropriate complementary feeding education in food secure populations and additional complementary food supplements in food insecure populationsInfant and young child feedingVitamin A supplementation between 6-59 months agePreventive zinc supplements between months of ageMicronutrient supplementation in children at riskSupplementary feeding for moderate acute malnutritionManagement of severe acute malnutritionManagement of acute malnutrition
20 Effect of Packages of Nutrition Interventions at 90% Coverage Number of lives savedCost per life-year savedOptimum 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 risk145,000(30, ,000)$159( )Management of acute malnutrition435,000(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 pregnancyPromotion of breastfeedingPromotion of appropriate complementary feedingVitamin A supplementationPreventive zinc supplementationTreatment of diarrhoea with zincRecognition 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 differenceIf 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 millionOn top of existing trends, the WHA targets for 2025 are reachable
27 Nutrition interventions Total Additional Annual Cost of Achieving 90% Coverage with Nutrition InterventionsNutrition interventionsCostSalt iodisation$68Multiple micronutrient supplementation in pregnancy (includes iron-folate)$472Calcium supplementation in pregnancy$1914Energy-protein supplementation in pregnancy$972Vitamin A supplementation in childhood$106Zinc supplementation in childhood$1182Breastfeeding promotion$653Complementary feeding education$269Complementary feeding supplementation$1359SAM management$2563Total$9559Data are 2010 international dollars, millions.
28 Paper 2 Key MessagesPromising 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