2 nutrition and lifestages

Nutrition Through the Lifecycle

Maternal Nutrition

Low Birth weight

Why focus on women’s nutrition?• First and foremost because women have a

basic right to food security and good health

• However, due to their multiple roles of reproducing, nurturing, caring and producing, the social, economic, health and development implications of women’s malnutrition can be devastating

Why focus on women’s nutrition?...• Consequences include

Infections

Obstructed labor

Low birth weight

Neonatal and infant mortality

Maternal mortality

Undernourished mothers are less productive and this

has economical implications as well as implications for

household food security

What is and why the lifecycle approach?

The Typical Scenario in AfricaA woman enters pregnancy undernourished, anemic and

probably deficient in other micronutrients →

She gives birth to an infant with LBW who immediately starts life at a disadvantage → → childhood and adolescence → →

The female adolescent enters womanhood & pregnancy malnourished….and the cycle continues!

The Lifecycle approach…why?• Focusing on female nutrition throughout the

lifecycle – from infancy through childhood to adolescence and the reproductive years may give greater dividends in terms of improved nutritional status of both mother and child

The Lifecycle approach…why?...• The benefits spill over to the elderly who

because of nutritional investments throughout the lifecycle are healthier in later years

• Elderly are a major resource for the care of infants and young children

• Healthier elders could translate into improved quality of care for infants and young children while reducing the burden of women in caring for sick elders

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• Maternal Nutrition

• Major Issues

Maternal Malnutrition:A Life-Cycle Issue

· Infancy and early childhood (0-24 months)– Suboptimal breastfeeding practices– Inadequate complementary foods – Infrequent feeding – Frequent infections

· Childhood (2-9 years) – Poor diets – Poor health care– Poor education

Maternal Malnutrition:A Life-Cycle Issue…

· Adolescence (10-19 years)– Increased nutritional demands– Greater iron needs – Early pregnancies

· Pregnancy and lactation – Higher nutritional requirements– Increased micronutrient needs – Closely-spaced reproductive cycles

Maternal Malnutrition:A Life-Cycle Issue…

· Throughout life– Food insecurity– Inadequate diets – Recurrent infections– Frequent parasites– Poor health care– Heavy workloads– Gender inequities

The IntergenerationalCycle of Malnutrition

Child growth failure

Early pregnancy

Small adult women

Low birth weight babies

Low weight and height in teens

ACC/SCN, 1992

Maternal Malnutrition…

• Women who were malnourished as infants are more likely to give birth to malnourished babies

• Infant malnutrition, especially for girls, effectively perpetuates poverty, hunger, and malnutrition across generations

Maternal Nutrition and the MDGs• Improved maternal nutrition is essential for

attaining many of the MDG targets:

– Reducing maternal mortality by three quarters between 1990 and 2015

– Reducing hunger and malnutrition (Goal 1)

– Achieving universal education (Goal 2)

– Promoting gender equality and women’s empowerment (Goal 3)

Mechanism for poverty transmissionthroughout the life course

Poverty is biologically transmitted across generations through malnutrition

– Maternal underweight• Key risk factor in low birth weight

– Low birth weight• Risk factor for child stunting and underweight

Maternal undernutrition

–Chronic energy deficiency

–Micronutrient deficiencies

Chronic energy deficiency• Maternal body-mass-index (BMI)

= Weight (in kg)/height (in m) squared,

• Measure of chronic energy deficiency (CED)– Severe CED : BMI<16

– Mild/moderate CED : BMI 16 - 18.49

– No CED : BMI 18.5 - 24.99

– Overweight : BMI 25 - 29.99

– Obese: BMI >=30

Major Interventionsin Maternal Nutrition

· Improve weight and height

· Improve micronutrient status

Improving Maternal Weight

· Increase caloric intake

· Reduce energy expenditure

· Reduce caloric depletion

Improving Maternal Height

· Weight increases can be achieved within a

woman’s reproductive life’

May not be true for height

· Increase birth weight

· Enhance infant growth

· Improve adolescent growth

Optimal Behaviorsto Improve Women’s Nutrition

Early Infancy: Exclusive breastfeeding to about six months of age

Optimal Behaviorsto Improve Women’s Nutrition…

• Late Infancy and Childhood: – Appropriate

complementary feeding from about six months


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• Late Infancy and Childhood:

Continue frequent on-demand breastfeeding to 24 months and beyond


Pregnancy:• Increase food intake• Take iron+folic acid supplements daily• Reduce workload

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Lactation:• Increase food intake• Take a high dose

vitamin A at delivery• Reduce workload

Vitamin A PostpartumSupplementation

• Recommendations

Current (WHO):

200,000 IU in 1 dose, as soon as possible after delivery

Proposed:

400,000 IU in 2 doses of 200,000 IU at least 1 day apart, as soon as possible after delivery


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• Delay first pregnancy

• Increase birth intervals


At all times:• Increase food intake if underweight• Diversify the diet• Use iodized salt• Control parasites• Take micronutrient supplements if needed

Improving Women’s Micronutrient Status

· Dietary modification

· Parasite control

· Fortification

· Supplementation

Dietary Modification to Improve Women’s Micronutrient Status

Increase:

· Micronutrient intake

· Bioavailability of micronutrient intake

Parasite Control to Improve Women’s Micronutrient Status

Reduce parasite transmission:

Improve hygiene

Increase access to treatments

Fortification to Improve Women’s Micronutrient Status

Medium-term strategy:· Improves micronutrient intake· Without changing food habits

Requires:· Appropriate nutrient fortificant· Appropriate food vehicle

Examples of Micronutrient Food Fortification

Vitamin A in sugar

Iron in wheat flour

Iodine in salt

Multiple fortification iron + iodine in salt iron + vit B in wheat flour

Supplementation to Improve Women’s Micronutrient Status

Preventive or therapeutic

Daily or periodic

Targeted to groups

Mass distribution

Iron+Folic Acid Supplementationfor Women of Reproductive Age

Prior to and between pregnancies:

Periodic supplementation (60 mg of iron and

400 μg folic acid) daily for 3 months for: ● Girls before puberty and during adolescence● Women of childbearing age

Elements of a Successful Supplementation Program

· Supplement supply· Delivery system· Women’s demand and compliance· Monitoring and evaluation

Supplement Supply

· Data-based ordering

· Timely procurement process

· Timely distribution to delivery points

Supplement Delivery System

· Accessible to target population

· Appropriate Staff:- Motivated- Approachable- Supportive- Adequately trained

Women’s Demand and Compliance

· Communications component- Community awareness

- Information on side effects

· Good quality supplements

Monitoring and Evaluation

· Monitor at all levels:- Supply- Coverage- Compliance- Communications component

· Evaluate impact on prevalence

Low Birth Weight (LBW)

Low Birth Weight….• Birthweight is the first weight of the foetus

or newborn obtained after birth.

• For live births, birthweight should preferably be measured within the first hour of life, before significant postnatal weight loss has occurred.

LBW - Incidence

• The incidence of low birthweight in a population is the percentage of live births that weigh less than 2,500 g out of the total of live births during the same time period.

LBW - Measurement• Data Sources:

– Developed countries - service-based data and national birth registration systems

– Developing countries - national household surveys, as well as data from routine reporting systems

• Since about 1990 from mothers participating in nationally representative household surveys, mostly the USAID supported DHS and the UNICEF-supported MICS.

LBW – Measurement…• Births that were weighed were more likely to

involve mothers who were – better educated and resided in urban areas,– in a medical facility and with assistance from skilled

health personnel.

• These characteristics are generally associated with higher birthweights and, therefore, the resulting estimates were still likely to underestimate the level of low birthweight.

Low birth weight (LBW) – Definition and Magnitude

• Birth weight below 2500 grams (5.5 pounds),– 30% in South Asia,

– 14% in sub-Saharan Africa,

– 15% in Middle East and North Africa,

– 10% in Latin America,

• Very low birth weight : <1,500 grams

LBW - Significance

• Low birth weight infants:– High risk of neonatal or infant mortality,

– Less likely to catch-up significantly,

– High risk of developmental deficits,

– More likely to be underweight or stunted,

– Consequences extend into adulthood,

• “fetal origins of disease hypothesis”

Causes of LBW

• Intrauterine growth retardation (IUGR)– Intrauterine growth that is less than expected for

length of gestation

– Small for gestational age (SGA)

– More common in Developing countries

• Preterm birth (<37 weeks)– Short duration of pregnancy

– More common in Developed countries

Causes of LBW…

– For the same gestational age, girls weigh less than boys, firstborn infants are lighter than subsequent infants, and twins weigh less than singletons;

– Birthweight is affected to a great extent by the mother’s own foetal growth and her diet from birth to pregnancy, and thus, her body composition at conception;

Causes of LBW…– Poor maternal nutrition during pregnancy

accounts for 14% of IUGR in developing

countries

– Maternal stunting may account for 18.5%

Causes of LBW…

Developing countries;– 50% of all IUGR in rural areas of developing

countries attributable to;

• small maternal size at conception

• low gestational weight gain

Causes of LBW…

Other causes of IUGR, developing

countries;– Malaria in endemic areas

– Maternal infections

– Abnormal placental blood flow or structure

– Foetal infections

Causes of LBW…

Developed countries– Premature delivery

– Cigarette smoking during pregnancy

– Low gestational weight gain

– Low BMI at conception

– Maternal undernutrition - uncommon

– Folic acid deficiency may increase risk of preterm delivery

Classification of LBW/PTD

Gestational age LBW Normal BW

>37 weeks IUGR Normal

<37 weeks Preterm/ Preterm

and/or IUGR

PTD and IUGR asdeterminants of LBW

• Preterm infant may be LBW but have an appropriate weight for its gestational age– LBW only because it was born early

• Preterm infant may also be growth retarded– LBW because of both shortened gestation and

growth retardation

Three types of IUGR

• Group 1:– Born after 37 weeks of gestation and weight less

than 2,500 g at birth

• Group 2:– Newborns are preterm and weigh less than the

10th percentile at birth

• Group 3:– Weigh less than the 10th percentile, but have abirth weight greater than 2,500 g

Types of IUGR

Epidemiology of IUGR

• In 2000, an estimated 11.0% of newborns in developing countries, or 11.7 million infants, have low birth weight at term

• In Asia, 20.9% of newborns are affected, and the sub-region accounts for 80% of all affected newborns worldwide

IUGR…

IUGR affects more newborns than low birth weight;– about 24% or 30 million newborns per year in

developing countries

• Major global human development problem;– profound short- and long-term consequences for

individuals, communities, and whole populations

Consequences of LBW

– Increased risk of morbidity and mortality

– Poor neurodevelopmental outcomes

– Reduced strength and working capacity

– Increased risk of chronic diseases in adulthood

LBW - Prevalence and Trend

Low Birth Weight - Trends (2000-2011)

2000 2005 2011 2000 2005 2011

6

21 21

814

11

28

7 9

6672 70

very small smaller than average Average or larger

Reported birth weight < 2.5 kg

Mothers’ subjective assessment

Only 5% of children in Ethiopia are weighed at birth in 2011

Trends in LBW - LBW on the rise between 1976-1996 in Addis Ababa

70's 80's 90's0

2

4

6

8

10

12

5.8

7.3

11.3Chart Title

Year

Perc

ent L

BW

The odds of LBW in the 90's was 52% higher compared to the 70's

Trends in LBW - Regions

Study area Year of Survey Prevalence

Gondar 196719881996

13.8%11.1%17.8%

Addis Ababa 1997 9.1%

Jimma 20032005

22.5%11.0%

LBW and Malaria

Study area

Sample size Prevalence

Gambella(2003)

Infected Uninfected With placental malaria

Without placental malaria

9 159 44 14

Prevalence of placental malaria: 5%

J. Infect. Dis. 187:1765– 1772.

Factors associated with LBW– Teen age pregnancy (<20 years)

– Shorter stature (<= 150cm)

– Short birth intervals and

– Mothers who come late for antenatal visit and had complications during pregnancy.

– Infections (Malaria…)(Gebremariam A. East Afr Med J. 2005 Nov;82(11):545-6)

• Infant with Low birth weight

• Infancy & childhood up to 5 years - Stunting - Underweight - Wasting

• Women Chronic energy deficiency

Nutritional Status of Children Under Age Five

Vulnerable period

Duration of Breastfeeding by Region

Amhara

Gambela

Tigray

SNNP

Addis Ababa

Affar

Oromiya

Benishangul-Gumuz

Somali

Harari

Dire Dawa

>36>36

26

26

26

25

25

23

22

21

20

How Does Breastfeeding Differ by Country?

Uganda 2000-01

Tanzania 2004-05

Kenya 2003

Eritrea 2002

Mozambique 2003

Malawi 2000

Rwanda 2005

Ethiopia 2005

21

21

22

23

23

24

25

26Chart Title

Exclusive Breastfeeding Under 6 Months

Exclu-sively

breastfed49%

Plus plain water only15%

Plus wa-ter-based

liquids/juice5%

Plus other milk18%

Not breast-feeding

1%

Plus comple-mentary

foods14%

Chart Title

Median Duration of Breastfeeding

Any breast-feeding

Exclusive breastfeeding

Predominant breastfeeding

25.8

2.14.4M

edia

n du

ratio

n in

m

onth

s

Complementary Foods – EDHS 2005

14% of breastfed children under 6 months are already consuming solid or mushy food.

Only 54% of breastfed children age 6-9 months consume solid or mushy food.

Trends in Children’s Nutritional Status (EDHS 2000-2011)

underweight wasting Stunting

47

11

52

38

11

47

29

10

44

EDHS 2000 EDHS2005 EDHS 2011

perc

ent

Evolution of child malnutrition in Ethiopia from 1983-2005 (WMS & DHS)

1983 1992 1996 1997 1998 2000 2005

6064 66 67

5552

4747 47

4347 38

8 8 8 8 9 11 11

Stunting Underweight Wasting

Trends in Child Malnutrition – Urban-Rural difference

1983 1992 1996 1997 1998 2000 20050 0

5855

41 42

30

6064

67 69

5653

48

0 0

3437

3034

23

0 0

48 4844

49

40

0 06

9

8 6 68 8

8

8

911 11

Urban Stunting Rural Stunting Urban Underweight Rural Underweight

Urban Wasting Rural wasting

•Child Malnutrition – Comparison with other African countries

Senegal Egypt Tanzania Kenya* (2003)

Rwanda Ethiopia

16 18

2730

45 47

Prevalence of Stunting, DHS 2005

Egypt Rwanda Tanzania Kenya* (2003)

Senegal Ethiopia

4 45

6

8

11

Prevalence of Wasting, DHS 2005

Egypt Rwanda Tanzania Kenya* (2003)

Senegal Ethiopia

6

1720 20

23

38

Prevalence of Underweight, DHS 2005

key determinants ofGrowth Faltering in Ethiopia

• household resources

• parental education

• food prices and

• maternal nutritional knowledge

• Infant with Low birth weight

• Infancy & childhood up to 5 years

• Women Chronic energy deficiency - BMI & Height

Urban Rural Total

23

3230

19

28 27

20

2927

DHS 2000 DHS 2005 DHS 2011

Percent women BMI <18.5kg/m2, (EDHS 2000-2011)

Percent Women BMI <18.5 (DHS 2000-2005)

TigrayAffar

AmharaOromiya

SomaliB-Gumuz

SNNPGambela

HarariAddis Ababa

Dire Dawa

0 10 20 30 40 50 60

35

42

31

29

48

38

31

39

25

18

27

38

33

27

24

35

33

27

39

21

15

24

DHS 2005 DHS 2000

Ethiopia

Rwanda

Tanzania

Senegal

Kenya

Egypt

27

10

10

12

12

0.5

Percent <18.5 BMI, DHS 2005

Trends in Percentage below 145 cm(EDHS 2000-2011)

Total Urban Rural

4

3

4

3

2

33 3

4

DHS 2000 DHS 2005 DHS 2011

Percentage below 145 cm (EDHS 2000-2005)

Tigray

Affar

Amhara

Oromiya

Somali

B-Gumuz

SNNP

Gambela

Harari

Addis Ababa

Dire Dawa

0 1 2 3 4 5 6 7 8

5

4

4

3

2

3

4

4

2

3

1

3

4

4

2

2

7

4

1

2

2

1

DHS 2005 DHS 2000

•Factors associated with Poor Maternal Nutrition

Birth intervals - EDHS 2000-2011

7-17 18-23 24-35 36-47 48-59 60+

811

38

24

19

1

DHS 2000 DHS 2005 DHS 2011Months since the preceding birth

per

cen

tag

e

Birth intervals < 24 months in 2011 = 20%

25-29 30-34 35-39 40-44 45-49 25-49

20

19 19

18

19 1919 19 19 19 19 1919 19 19 19 19 19

Median age at first birth, EDHS 2000-2011

DHS 2000 DHS 2005 DHS 2011

Current age

Med

ian

ag

e at

fir

st b

irth

•Overweight and Obesity

Emerging Nutrition Problem??

Overweight and Obesity in EDHS 2011

Total Urban Rural

5.7

14.9

2.6

4.7

12.1

2.31

2.8

0.4

Overweight or Obese Overweight Obese

Overweight/obesity trends – EDHS 2005-2011

Overweight or Obese

Overweight Obese

4

3

0.7

6

5

1

2005 2011

Overweight and obesity trends in Urban areas – EDHS 2005-2011


14

12

2

15

12

3

Urban 2005 Urban 2011

Overweight and obesity trends in Rural areas – EDHS 2005-2011


2 2

0.3

2.6

2.3

0.4

Rural 2005 Rural 2011

Tigray

Affar

Amhara

Oromiya

Somali

B-Gumuz

SNNP

Gambela

Harari

Addis Ababa

Dire Dawa

2

4

2

5

10

2

3

2

10

18

14

3

4

4

5

16

3

6

7

14

20

19

Regional disparities in levels of Overweight or Obesity, EDHS 2005 - 2011

DHS 2011DHS 2005

Comparison with other countries

Ethiopia

Rwanda

Tanzania

Senegal

Kenya

Egypt

4

12

18

22

23

80

Percent Overweight or Obese, DHS 2005

2 nutrition and lifestages

Health & Medicine

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