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, 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

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Nutrition-Specific Interventions and Programs: How can they Help Accelerate Progress in Improving

Maternal and Child Nutrition?

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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

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Interventions Across the Lifecycle

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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

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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

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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

Breast Feeding Promotion-Effects on breast feeding rates

Outcome EstimatesEBF at Day 1 43% RR: 1.43 (1.09-1.87) increase

EBF at 4-6 weeks 30% (RR: 1.30, 95% CI: 1.19-1.42) increaseEBF at 6 month 90% (RR: 1.90, 95% CI: 1.54-2.34) increase

Effects on exclusive breastfeeding rates

Effects on NOT breastfeeding

Outcome Estimates

Not breast feeding at Day 1 32% (RR: 0.68, 95% CI: 0.54-0.87) decrease

Not Breast feeding at 1 month 30% (RR: 0.70, 95% CI: 0.62-0.80) decrease

Not breast feeding at 6 months 18% (RR: 0.82, 95% CI: 0.77-0.89) decrease

Behavior Change Communication for Improved Complementary Feeding

Outcome EstimatesComplementary 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)

Behavior Change Communication for Improved Complementary Feeding

Outcome EstimatesComplementary 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 populationsHAZ SMD: 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)

Behavior Change Communication for Improved Complementary Feeding

Outcome EstimatesComplementary 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 populationsHAZ SMD: 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)

underweight RR: 0.35 (95% CI: 0.16, 0.77)

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

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

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

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% o

f bir

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0 12 24 36Age in months

Died StuntedNot stunted

Modeling the Impact of Interventions: What’s New?

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Countries With High Burden of Malnutrition

These 34 countries account for 90% of the global burden of malnutrition

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Effect of Scale-up Interventions on Cause-specific Deaths

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 11.1-28.9%)

Severe wasting reduced overall by 61.4% (range 35.7-72%)

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

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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 12-59 months of age

Micronutrient supplementation in children at risk

•Supplementary feeding for moderate acute malnutrition •Management of severe acute malnutrition

Management of acute malnutrition

Effect of Packages of Nutrition Interventions at 90% Coverage

Nutrition interventions Number of lives saved

Cost per life-year saved

Optimum maternal nutrition during pregnancy 102,000(49,000-146,000)

$571(398-1,191)

Infant and young child feeding 221,000(135,000-293,000)

$175 (132-286)

Micronutrient supplementation in children at risk 145,000(30,000-216,000)

$159(106-766)

Management of acute malnutrition 435,000(285,000-482,000)

$125(119-152)

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Can community based nutrition programs reach the poor?

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)

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).

Community based Interventions Modeled

1. Multiple micronutrient supplementation in pregnancy2. Promotion of breastfeeding3. Promotion of appropriate complementary feeding4. Vitamin A supplementation5. Preventive zinc supplementation6. Treatment of diarrhoea with zinc7. Recognition and management of severe acute malnutrition

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Equity Analysis of Effect of Scale Up Nutrition Interventions

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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

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.

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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

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