What Can be Done and at What Cost Zulfiqar A Bhutta 12 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 amp Interventions Review Groups ID: 667315
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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, GhanaSlide2
Nutrition-Specific Interventions and Programs: How can they Help Accelerate Progress in Improving Maternal and Child Nutrition?2Slide3
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 up3Slide4
Interventions Across the Lifecycle4Slide5
Nutrition Interventions Reviewed5Slide6
Delivery Platforms Reviewed6Slide7
Delivery Platforms Reviewed7Slide8
Breast Feeding Promotion-Effects on breast feeding ratesOutcomeEstimatesEBF at Day 143% RR: 1.43 (1.09-1.87) increaseEBF at 4-6 weeks30% (RR: 1.30, 95% CI: 1.19-1.42) increase
EBF at 6 month90% (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) decreaseSlide9
Behavior Change Communication for Improved Complementary Feeding Outcome EstimatesComplementary Feeding education alone in food secure populationsWAZSMD: 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) Slide10
Behavior Change Communication for Improved Complementary Feeding Outcome EstimatesComplementary Feeding education alone in food secure populationsWAZSMD: 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)
WAZ
SMD: 0·26 (95% CI 0·12, 0·41)Slide11
Behavior Change Communication for Improved Complementary Feeding Outcome EstimatesComplementary Feeding education alone in food secure populationsWAZSMD: 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)
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)Slide12
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 scaleSlide13
LiST modeling effects on mortality for 34 high burden countries: revised model 13Slide14
Modeling the Impact of Interventions: What’s New?14Slide15
Countries With High Burden of Malnutrition15These 34 countries account for 90% of the global burden of malnutritionSlide16
Effect of Scale-up Interventions on Cause-specific Deaths16Slide17
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 mortality 39% (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 11.1-28.9%) Severe wasting reduced overall by 61.4% (range 35.7-72%) 17Slide18
Effect of Scale-up Interventions on Deaths in Children Younger than 5 Years18Slide19
Packages of Nutrition Interventions19Slide20
Effect of Packages of Nutrition Interventions at 90% CoverageNutrition interventionsNumber of lives savedCost per life-year savedOptimum maternal nutrition during pregnancy102,000(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)
20Slide21
Can community based nutrition programs reach the poor?Slide22
All Community PlatformsMaternal 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)Slide23
All Community PlatformsMaternal 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). Slide24
Community based Interventions ModeledMultiple micronutrient supplementation in pregnancyPromotion of breastfeedingPromotion of appropriate complementary feedingVitamin A supplementationPreventive zinc supplementationTreatment of diarrhoea with zincRecognition and management of severe acute malnutrition Slide25
25Equity Analysis of Effect of Scale Up Nutrition InterventionsSlide26
Potential Impact of Scaling Up 10 Proven InterventionsContinued 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 reachable26Slide27
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$269
Complementary feeding supplementation
$1359
SAM management
$2563
Total
$9559
Data are 2010
international dollars
, millions.
27Slide28
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 upA 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 stuntingDelivery 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 outcomes28