1. Jump-Starting IYCF:

2. Infant nutritional status depends on the mother’s status

3. Starting in Pregnancy? Or Before?

4. Nutrient status of the mother Pre-pregnancy diet Pre-pregnancy diet Pre-pregnancy nutritional status Pre-pregnancy nutritional status Pre-pregnancy work load or activity level Pre-pregnancy work load or activity level Spacing between pregnancies Spacing between pregnancies

6. Measuring Adult Nutritional Status Body Mass Index BMI = weight (kg) / height (m) 2 60.5 kg / (1.6 m x 1.6 m) = 24

7. Effects of Maternal Nutrition Ability to nourish in-utero starting at conception Ability to nourish in-utero starting at conception Ability to provide quality breastfeeding without depleting her own nutrient stores Ability to provide quality breastfeeding without depleting her own nutrient stores Maintenance of her quality of life, productivity and capacity to care for child Maintenance of her quality of life, productivity and capacity to care for child

8. Nutrient Pre- Pregnancy During Pregnancy by Trimester During Lactation !st2nd3rd 0-6 mos. >6 months Energy 2200 kcal +0+240+452+500+400 Protein 46 g +25+25+25+25+25 Vitamin A 700 RAE +70+70+70+600+600 Iron 18 mg +9 mg +9+9+0+0 Folate 400 ug +200+200+200+100+100 Iodine 150 ug +70+70+70+140+140 Calcium 1000 mg +0+0+0+0+0 Zinc 8 mg +3 mg +4 mg Changes in Nutrient Needs

9. Physiological changes during pregnancy 40% increase in blood volume and 25% increase in red blood cell mass 40% increase in blood volume and 25% increase in red blood cell mass Increase in lung ventilating capacity and rate Increase in lung ventilating capacity and rate Fat deposition during first half of pregnancy Fat deposition during first half of pregnancy Rapid growth of fetus and placenta during second half of pregnancy Rapid growth of fetus and placenta during second half of pregnancy Synthesis of large quantities of new protein tissue - also require energy Synthesis of large quantities of new protein tissue - also require energy

10. Energy Intake during Pregnancy Increase roughly 200-300 kilocalories/day during second and third trimester Increase roughly 200-300 kilocalories/day during second and third trimester Depends or pre-pregnancy BMI Depends or pre-pregnancy BMI Underweight women may need more kcal Underweight women may need more kcal Active women must also decrease physical activity Active women must also decrease physical activity

11. Weight Gain During Pregnancy Average weight gain is 10 to 12 kg: Average weight gain is 10 to 12 kg: Fetus, placenta, amniotic fluid5 kg Fetus, placenta, amniotic fluid5 kg Maternal blood1 – 1.5 kg Maternal blood1 – 1.5 kg Maternal tissue fluid1 – 1.5 kg Maternal tissue fluid1 – 1.5 kg Uterus, breasts1 – 1.5 kg Uterus, breasts1 – 1.5 kg Maternal adipose tissue 4 kg Maternal adipose tissue 4 kg

12. Energy Needs during Lactation Increase by up to 500 kilocalories per day Increase by up to 500 kilocalories per day Fat stored during pregnancy can be used to satisfy this energy requirement Fat stored during pregnancy can be used to satisfy this energy requirement Increased energy intake does not result in increased milk production in adequately nourished women Increased energy intake does not result in increased milk production in adequately nourished women Sufficient amount of milk can be produced by women with low energy intake Sufficient amount of milk can be produced by women with low energy intake

13. Why so much energy for lactation? Human milk is about 70 kcal/100 ml Human milk is about 70 kcal/100 ml Maternal energy is converted with about 80% efficiency to milk energy Maternal energy is converted with about 80% efficiency to milk energy ~85 kcal of maternal energy needed to produce 100 ml of breast milk ~85 kcal of maternal energy needed to produce 100 ml of breast milk An average milk secretion of 750 ml per day, requires 640 kcal/day An average milk secretion of 750 ml per day, requires 640 kcal/day Some of this can come from stored fat Some of this can come from stored fat

14. Nutrient Quality of Breast Milk Energy, protein, and some mineral content is not affected by maternal dietary intake or stores Energy, protein, and some mineral content is not affected by maternal dietary intake or stores Vitamin C, thiamine, riboflavin, B6, B12, Vitamin A, iodine and selenium are dependent on maternal intake or stores Vitamin C, thiamine, riboflavin, B6, B12, Vitamin A, iodine and selenium are dependent on maternal intake or stores Maternal intake has minimal effect on content of zinc, iron, folate, Vitamin D, calcium and copper content of breast milk Maternal intake has minimal effect on content of zinc, iron, folate, Vitamin D, calcium and copper content of breast milk

15. Protein About 925 g of new protein are synthesized and deposited in mother and fetus About 925 g of new protein are synthesized and deposited in mother and fetus Average breast milk production per day - 750 ml with protein content of 1.25 g/100 ml Average breast milk production per day - 750 ml with protein content of 1.25 g/100 ml Adequate energy intake from carbohydrates is essential to assure new protein synthesis Adequate energy intake from carbohydrates is essential to assure new protein synthesis

16. Iron-deficiency anemia 50% of anemia is from iron deficiency 50% of anemia is from iron deficiency Absorption may be as important as low dietary intake Absorption may be as important as low dietary intake Inhibitors Inhibitors Heme vs. non-heme Heme vs. non-heme Other major causes of anemia: Other major causes of anemia: Malaria Malaria Helminthes Helminthes

17. Efficacy of Iron Supplementation World Bank review found that distribution was the limiting factor not utilization World Bank review found that distribution was the limiting factor not utilization Counseling on purpose is as important as counseling on controlling side effects Counseling on purpose is as important as counseling on controlling side effects Some concern that iron inhibits zinc and copper absorption Some concern that iron inhibits zinc and copper absorption

18. Actions to Prevent Anemia Promote intake of iron-rich foods, especially animal products and fortified foods Promote intake of iron-rich foods, especially animal products and fortified foods Provide iron supplementation to pregnant women Provide iron supplementation to pregnant women Continue supplementation for 3 months post-partum in areas with anemia prevalence >40 percent Continue supplementation for 3 months post-partum in areas with anemia prevalence >40 percent De-worming of pregnant women after first trimester, and lactating women, according to WHO protocol De-worming of pregnant women after first trimester, and lactating women, according to WHO protocol Prevent and control malaria Prevent and control malaria

19. Vitamin A Provide post-partum high-dose vitamin A supplementation to women Provide post-partum high-dose vitamin A supplementation to women If breastfeeding, within 8 weeks of delivery If breastfeeding, within 8 weeks of delivery If not breastfeeding, within 6 weeks of delivery If not breastfeeding, within 6 weeks of delivery Promote consumption of vitamin A-rich foods, including liver, fish, egg, and red and yellow fruits and vegetables Promote consumption of vitamin A-rich foods, including liver, fish, egg, and red and yellow fruits and vegetables Promote consumption of vitamin A-fortified foods Promote consumption of vitamin A-fortified foods

20. Iodine Sufficient iodine intake in pregnancy and lactation is essential in prevention of maternal and fetal hypothyroidism Sufficient iodine intake in pregnancy and lactation is essential in prevention of maternal and fetal hypothyroidism Insufficient iodine intake in pregnancy may have an adverse effect on fetus as early as 8-10 weeks of gestation Insufficient iodine intake in pregnancy may have an adverse effect on fetus as early as 8-10 weeks of gestation Iodine content of breast milk depends on iodine intake by lactating mother Iodine content of breast milk depends on iodine intake by lactating mother

21. Calcium about 30 g of Ca is accumulated in pregnancy to meet fetal needs and demands of lactation about 30 g of Ca is accumulated in pregnancy to meet fetal needs and demands of lactation absorption of Ca increases up to two times in the second half of pregnancy thus reducing needs for increased intake absorption of Ca increases up to two times in the second half of pregnancy thus reducing needs for increased intake Ca content of breast milk does not depend on calcium intake Ca content of breast milk does not depend on calcium intake

22. Zinc Some data suggest that Zn deficiency may cause intrauterine growth retardation of fetus Some data suggest that Zn deficiency may cause intrauterine growth retardation of fetus Zn levels in maternal serum decline during pregnancy (dilution effect) Zn levels in maternal serum decline during pregnancy (dilution effect) When Zn intake is low (less than 7.3 mg/day) absorption of Zn increases; When Zn intake is low (less than 7.3 mg/day) absorption of Zn increases; This may be sufficient to meet maternal needs without extra Zn supplements This may be sufficient to meet maternal needs without extra Zn supplements Zn absorption is decreased by Fe supplements Zn absorption is decreased by Fe supplements

23. Folic Acid Folate deficiency during pregnancy may cause megaloblastic anemia Folate deficiency during pregnancy may cause megaloblastic anemia Deficiency of folate in pregnancy is related to occurrence of neural tube defects in fetus Deficiency of folate in pregnancy is related to occurrence of neural tube defects in fetus The critical period for preventing neural tube defects is often before pregnancy is diagnosed The critical period for preventing neural tube defects is often before pregnancy is diagnosed Folate in foods is destroyed by boiling Folate in foods is destroyed by boiling

24. Essential Nutrition Actions 4. Prevention of vitamin A deficiency for women 5. Promotion of adequate intake of iron and folic acid for women 7. Promotion of optimal nutrition for women: Consume more food during pregnancy and lactation Consume more food during pregnancy and lactation Pregnancy: 285 extra kcal/day Pregnancy: 285 extra kcal/day Lactation: 500 extra kcal/day Lactation: 500 extra kcal/day Increase protein intake during pregnancy and lactation (e.g. pulses, animal source foods, oilseeds) Increase protein intake during pregnancy and lactation (e.g. pulses, animal source foods, oilseeds) Provide iron/folic acid supplementation for pregnant women Provide iron/folic acid supplementation for pregnant women Treat and prevent malaria Treat and prevent malaria De-worm during pregnancy in areas where helminths are a determinant of anemia De-worm during pregnancy in areas where helminths are a determinant of anemia Provide post-partum vitamin A supplementation Provide post-partum vitamin A supplementation Promote consumption of iodized salt Promote consumption of iodized salt

25. What to do in the field? At the Community Level: BCC: incorporate maternal nutrition messages at key contact points BCC: incorporate maternal nutrition messages at key contact points Promote increased caloric consumption of pregnant and lactating women and decreased physical activity Promote increased caloric consumption of pregnant and lactating women and decreased physical activity Promote improved dietary diversity among all women of reproductive age Promote improved dietary diversity among all women of reproductive age Promote consumption of fortified foods Promote consumption of fortified foods Engage spouses and in-laws during home visits Engage spouses and in-laws during home visits Promote uptake of key maternal nutrition services Promote uptake of key maternal nutrition services Home Food Production of nutrient-rich animal foods, fruits and vegetables Home Food Production of nutrient-rich animal foods, fruits and vegetables Food supplementation to food insecure households Food supplementation to food insecure households Food fortification: vitamin A, iron/folic acid, and iodine Food fortification: vitamin A, iron/folic acid, and iodine

26. With the Health Services Micronutrient supplementation: vitamin A and iron/folic acid Micronutrient supplementation: vitamin A and iron/folic acid Complementary maternal health services Complementary maternal health services Malaria prevention and treatment Malaria prevention and treatment Helminth prevention and treatment Helminth prevention and treatment Develop and strengthen referral systems Develop and strengthen referral systems

27. When intervention is urgent: >10% of adult population has a BMI 10% of adult population has a BMI <18.5 For women, based on pre-pregnancy weight For women, based on pre-pregnancy weight >15% of newborns are LBW ( 15% of newborns are LBW (<2500g) = high public health concern

28. Thank-you