Advancing Nutrition for Global Health:From Discovery Research to Implementation Science

Wafaie FawziNovember 15, 2018

Outline

• Undernutrition burden is going down but remains high: Essential Actions

• Double burden is a rising challenge: Multi-sectoral Interventions needed

• Gaps in implementation and next steps

Mortality in Early Life

Citation: UNICEF 2015a

Causes of child mortality

Recall that there were an estimated 5.9 million child deaths in 2015

Pneumonia: 0.8 million (16%)

Diarrhea: 0.5 million (9%)

Malaria: 0.3 million (5%)

Citations: WHO 2016, Black 2013

Malnutrition(2.6 million

deaths)

Timing of undernutrition

Citations: Shrimpton 2001

• Most DALYs lost due to underweight occur in infants and young children. The first 2 years are critical.

Global Stunting Burden

Citation: UNICEF/WHO/World Bank 2016

Burden of Chronic Malnutrition (age <5 y)

Citation: Murray 2015

Regional Stunting Numbers

Citation: UNICEF/WHO/World Bank 2016

Consequences of Undernutrition

Nutrition and Child Mortality

Citation: Black 2013

Stunted Children Have Lower ECDI Scores than Non-Stunted Children

Citation: McCoy 2016

Improvement in early life physical growth (current prevalence of

delay)

Improvements in future educational

attainment

Net present value of additional

lifetime earnings

Principal DataSources

Longitudinal studies measuring effect of

preschool developmental deficiencies on

educational outcomes

Country-specific wage projections,

UN population data

Nutrition Impact Model Study (NIMS)

Increase in wage due to increased

education

Published country-specific studies on

returns to education

ModelStage

Years of Educational Attainment Lost

Citation: Fink 2016

Global Estimates of Educational and Economic Gains

Globally, under a very conservative set of assumptions, growth faltering causes

• a loss of 69 million years of educational attainment per birth cohort

• a total wage loss of US$ 177 billion at current exchange rates

Citation: Fink 2016

Schematic of pathway from risk factor exposure to economic impact

Main Global Results

• Fetal restrictions (32%) and environmental factors (22%) account for the largest proportion of stunting

Citation: Danaei 2016

Essential Nutrition Actions

Balanced P-E supplements for stillbirthMacronutrients formaternal health

Lecture 10 | April 6, 2018Citations: Ota 2015

Balanced P-E supplements for SGAMacronutrients formaternal health

Lecture 10 | April 6, 2018Citations: Ota 2015

WHO Recommendations

Citations: WHO 2017

Balanced energy and protein supplementation in pregnancy

“In undernourished populations, balanced energy and protein dietary supplementation is recommended for pregnant women to reduce the risk of stillbirths and small for gestational age neonates.”

Prevalence of Anemia

~1.6 billion people are anemic (23% of global population)

Stevens, Lancet Global Health 2013

Burden and consequences of Preterm, SGA, LBW

Citations: Lee 2013

Daily oral iron supplementation in pregnancyand risk of anemia (Hb <11 g/dL) at term

Citations: Pena-Rosas 2012

70% Reduction (95% CI: 54-81%)

Daily oral iron supplementation in pregnancyand risk of LBW (<2500 g)

Citations: Pena-Rosas 2012

19% Reduction (95% CI: 3-32%)

WHO guidelines on iron supplementationduring pregnancy

Citations: WHO 2016

>40% anemia: 60 mg

Iron for prevention of anemia in pregnancy has been WHO recommended since 1968

Prevalence of micronutrient deficiencies during the first trimester among pregnant women in Nepal

Christian. Annu Rev Nutr 2010

Citations: Smith et al. Lancet GH 2017

Prenatal Multiple Micronutrient Supplements

• Compared with IFA alone, MNS with IFA provided greater reductions in neonatal mortality, small-for-gestational age and preterm birth).

• Greater benefit was noted among:

- females newborns compared to males

- anemic pregnant women

- underweight women

- women who started before 20 weeks gestation

- women with high adherence (≥95%)

Arsenault et al. J. Nutr. 2013

Risk of calcium deficiency by dietary intake

Citations: Hofmeyr 2014

Calcium supplementation among deficient womenEffect on Pre-eclapmsia

Citations: Hofmeyr 2014

Calcium supplementation and maternal death/morbidity

WHO. Guideline: Calcium supplementation in pregnant women. Geneva, World Health Organization, 2013.

CALCIUM

Vitamin A Deficiency 2013, All Ages

Stevens, Lancet 2015

RCTs Vitamin A versus placebo for children 6-23 monthsn= 165,000+ children

24% Reduction in risk of all cause mortality (95% CI: 17-31%)

Mortality and suboptimal breastfeeding

Citations: Black 2008

• Relative risks for suboptimal breastfeeding versus exclusive breast-feeding from 0-5 months and any breastfeeding from 6-23 months.

IYCF Interventions Complementary feeding

Citations: WFP Nutrition Service

Social and Behavior Change Communication (SBCC): example, counseling to promote optimal practices (but often includes a collection of strategies)

Photo credit: Peggy Koniz-Booher/SPRING

Example of counseling cards

Community health worker counseling a new mother

Wasting

Coverage of Essential Nutrition Actions

Global state of infant feeding

Citations: UNICEF 2016

Coverage vitamin A supplementation for children 6-59 months of age

UNICEF, 2013

Coverage of IFA for at ≥90 days in Pregnancy

IFPRI, 2014

Implications

• Effective actions exist, often translated into policy and national guidelines

• Coverage is low

• Overall shift towards to comprehensive interventions supporting both mothers, children and general environment are likely to have larger impact than programs focusing on single risk factors

Outline

• Undernutrition burden is going down but remains high: Essential Actions

• Double burden is a rising challenge: Multi-sectoral Interventions needed

• Gaps in implementation and next steps

OverweightAssessing Status:Anthropometry

The double burden of malnutrition

Overweight prevalence: adults

Citations: Ng 2014

Overweight (BMI≥25 kg/m2) among adults aged ≥20 years

1980 1990 2000 2010 2013

Overweight prevalence: children <5 years

Citations: UNICEF/WHO/World Bank 2016

Burden of obesity (adults)

Citations: Murray 2015

Global burden of disease study. Lancet. 2013.

Six of the top 11 risk factors driving the

global burden of disease are related to

DIET:

Double Duty Interventions

World Health Organization. (2017). Double-duty actions for nutrition: policy brief. World Health Organization. http://www.who.int/iris/handle/10665/255414. License: CC BY-NC-SA 3.0 IGO

Optimizing Food Systems to Address the

Double Burden

Sources: Tanzania National Nutrition Survey 2014

Bread Basket of Tanzania

Global Panel on Agriculture and Food Systems for Nutrition. 2014. How can Agriculture and Food System Policies improve Nutrition? Technical Brief, London,

Demand for food increasing with population growth

Executive Summary, September 2016, Global Panel on Agriculture and Food Systems for Nutrition.

Women = 43% Ag workforce in developing countries; up to 50% in Asia and Africa

Home production

vs

Markets

60Source: HLPE

Chelsey Canavan, 2017.

Outline

• Undernutrition burden is going down but remains high: Essential Actions

• Double burden is a rising challenge: Multi-sectoral Interventions needed

• Gaps in implementation and next steps

Global Nutrition Targets 2025

• Agreed upon by the World Health Assembly (WHO) in 2012.

Citations: WHO 2016d

Vision for our field through lens of SDGs

Integration is Key

Integration

• Integrate across sectors

• Integrate prevention and treatment measures

• Integrate across the life cycle

• Integrate discovery and implementation

• Integrate research and training

Africa Research, Implementation Science and Education Network (ARISE Network)

HSPH and the Africa Academy for Public Health, a training and capacity building organization based in Dar es Salaam, jointly established the Africa Research, Implementation Science, and Education Network (ARISE).

http://www.aaph-tz.org/

Ending Preventable Child Death in a Generation

Glass, JAMA. 2012; 308(2): 141-142

WHO Global Accelerated Action for the Health of Adolescents (AA-HA!), 2017