Public Nutrition: Policies and Programs INHL 613 Tues – Thurs 3.00 – 4.40 12 Jan – 2 Mar 2010

Public Nutrition:

Policies and Programs

INHL 613

Tues – Thurs 3.00 – 4.40

12 Jan – 2 Mar 2010

Course.

1. Principles and introduction

2. Community-based Health and Nutrition Programs

3. Micronutrient Programs

4. National planning exercise.

1. What are nutrition and public nutrition?

2. Consequences of malnutrition (hence: why bother?)

3. Causes of malnutrition to tackle (what to do about it?)

4. Brief epidemiology

5. Context and program principles

Introduction

TABLE 23. Estimated reductions in the disease burden (% DALYs lost) in developing countries (all population groups, all causes), from children underweight or deficiencies of vitamin A (clinical), iodine (measured as goiter), and anemia; from the direct effect (the deficiency considered as a disease itself) and as a risk factor for other diseases (infectious diseases only included in estimating reduction).

Note: underweight refers to children 0-59 months, < - 2 SDs weight-for-age; vitamin A deficiency is calculated from clinical deficiency in children 0-59 months; anemia refers to women 15-49 years; IDDs refers to iodine deficiency disorders, all ages, calculated from goiter prevalences. Methods are given in the source. Source: Mason, Musgrove & Habicht, (2003), table 10: [39]

Direct effect As risk factor Total Child underweight 1.0% 14.0% 15.0% Vitamin A deficiency 1.0% 4.5% 5.5% Anemia 3.3% 0.3% 3.6% IDDs 4.7% 3.7% 8.4% Total 10.0% 22.5% 32.5%

What does ‘nutrition’ cover? Consequences …

For children:•Health (direct and risk factor – see DALYs)•Survival/mortality risk•Intellectual development, educational result•Nutritional status (micronutrients, growth – affects future earnings)

For women:•Health (direct and risk)•Reproduction, intra-uterine development in pregnancy•Nutritional status (especially anemia)

For all:•Health•Activity, productive and discretionary•Freedom from hunger

These apply to undernutrition and obesity: we deal mainly with undernutrition.

"PUBLIC NUTRITION

includes the following activities:

an understanding and a raising of awareness of the nature, causes and consequences of nutrition problems in society;

epidemiology, including monitoring, surveillance, and evaluation;

nutritional requirements and dietary guidelines for populations;

programs and interventions: their design, planning,

management, and evaluation;

community nutrition and community based programs;

public education, especially nutrition education for behavioral change;

timely warning and prevention and mitigation of emergencies, including use of emergency food aid;

advocacy and linkage with, for example, population and

environmental concerns;

public policies relevant to nutrition in several sectors, for example, economic development, health, agriculture, and education.”

Source: letter to Am J Clin Nutr, March 1996,63399-400, Mason, Habicht, Greaves, Jonsson,

Kevany, Martorell, and Rogers.

‘Public

Nutrition…’

Mortality risk

J Nutr.124:2106S-2122S, 1994

Source: Lancet nutrition series #1, 2008

15-20 years later

Maternal and child undernutrition: consequences for adult health and human capital

Source: Lancet nutrition series #2, 2008

Source: 2nd and 6th UN World Nutrition Report/Tulane.

DRAFT

Nutrient Size (req/day) Role, reason Deficiencies

1. CHOs, Fats, N(protein: AAs)

Up to 500 g Energy, buildingblocks – structure,metabolism

Diverse clin signs. Not clearly linked torole.

2. Na, K, Ca. Up to 5 g Solute (seawater),homeostasis

Not really seen

3. Phosphate, Cl Up to 5 g As 2 Not really seen

4. Vit C Up to 0.1 g, 100mg

Antioxidant in mostcells; enzyme lostin evolution

Scurvy. Not clearlyrelated to function.

5. B-vits Up to 50 mg Co-factors inmetabolism(opportunisticevolution)

Specific signs, notclearly related tofunction

6. Essential Aasand FAs

... g Structure,metabolism; like B-vits

Some specificsigns, but not wellknown nor clearlyrelated to function

7. Metals: Fe, Zn,Cu, Mg, Mn, ...

1 – 10 mg(available)

a) Fe: carry O2

b) active sites ofenzymes (incl. Fe)c) other (e.g.cognitive)

a) anemia andcorrelatesb) non-specific orno signs (e.g. Zn)c) research area

8. I, vit D mcg Hormones, controlof homeostasis,growth, etc.

Specific signs(IDDs, rickets)when severe.

9. Vit A mcg a) visual cycleb) membranes

Specific signswhen severe; mild,mortality effect

plus almost all affect immune system

‘Nutrition…’

What does ‘nutrition’ cover? Causes and interventions.

See various frameworks, e.g. UNICEF – proximal causes:•Poverty and food security•Health environment, access to services•Care …

(Converse of hunger, sickness, and neglect)These interact and have important feedback loops (e.g. see malnutrition-infection spiral). More distal causes often are contextual rather than intervenable upon.

Time and biology are crucial – intra-uterine development (even at conception) has major influence (even on next generation).

Context, and program interventions: context determines whether interventions are effective; often cannot be quickly changed.

Single interventions are of well-known effectiveness, but they also importantly interact and have feedback loops. Issues are HOW to sustainably support them, and combine them.

Inadequatedietary intake Disease

Malnutrition and death

Inadequateaccess to food

Inadequate carefor mothers andchildren

Insufficient healthservices and un-healthy environ-

ment

I na d e q u a t e e d u c a t i o n

Potentialresources

Political and ideological superstructure

Economic structure

Formal and non-formal institutions

Outcomes

Immediatecauses

Underlyingcauses

Basiccauses

Source: Redrawn from UNICEF, 1990 [39]

Figure 1.8. Conceptual framework for the causes of malnutritionin society

Inadequate dietary intake

Weight loss Growth faltering Immunity lowered

Mucosal damage

Disease: - incidence - severity - duration

Appetite loss Nutrient loss Malabsorption Altered metabolism

Malnutrition-infection cycle

Normal weight

Infection

Mild underweight

Worse Infection

Worse Infection

Severe or Fatal Infection

Moderate underweight

Severe underweight

Spiral of malnutrition and infection

Better nutrition

Time

Source: Lancet nutrition series #3, 2008

Epidemiology

Source: Lancet nutrition series #1, 2008

0 20 40 60

Underweight

Anemia

VAD

IDD

Figure 13. Summary of estimated regional prevalences of underweight, anemia, vitamin A deficiency (sub-clinical), and IDDs, in pre-school children, c.1995 (see table 8 for data)

Table 8Illustrative Table of Prevalences of Nutritional Problems and Implied Overlap of Deficiencies in Preschool Children

RegionUnderweight

(1995)Anemia

(1975-97)Vitamin A Deficiency

(sub-clinical)1995

IDD Affected1985-1996

With 2 or more NutritionalDeficiencies

Prev-alence

Est. No.affected(millions)

Prev-alence

Est. No.Affected(millions)

Prev-alence

Est. No.Affected(millions)

Prev-alence

Est. No.Affected(millions)

PrevalenceEst. No.Affected(millions)

South Asia 52% 87.4 52.7% 93.8 35.6% 59.5 25.3% 42.5 27.4 C 35.6% 46.1 C 59.8

Sub-Saharan Africa 30% 30.9 33.1% 34.1 35.3% 36.0 29.2% 30.1 11.7 C 35.2 % 12.1 C 36.3

Middle East/ North Africa 16% 7.4 38.3% 17.7 9.8% 4.2 24.0% 11.1 9.2 C 24.0 % 4.3 C 7.4

East Asia / Pacific 23% 39.3 14.1% 20.0 18.2% 29.6 18.2% 31.1 4.2 C 18.2 % 8.2 C 31.1

Latin America/Caribbean 11% 6.2 22.9% 13.0 19.6% 10.2 15.6% 8.8 4.5 C 19.6 % 2.5 C 11.1

TOTAL 31% 171 35 % 190 26 % 140 23 % 124 13 C 27% 73 C 146

Context

C o n t r ib u t io n s t o r e d u c in g u n d e r w e ig h t .

- 1

- 0 . 5

0

0 . 5

1

1 . 5

2

2 . 5

3

3 . 5

T h a i I n d ia C a m e r o o nChan

ge in

uwt

pre

v, pp

ts/y

r

B a s eG D PL itH l t hE x p la in e dR e s F in a l

M o d e l: c h a n g e in u n d e r w e ig h t = 0 .4 5 3 – 0 .1 0 2 ( G D P g r o w th , % / y r ) – 0 .0 0 9 2 ( w o m e n ’s l i t e r a c y le v e l, % , a v e o f 1 9 8 0 /9 5 ) – 0 .0 4 8 ( m e a s le s im m u n iz a t io n , c h a n g e b e tw e e n s u r v e y s , p e r c e n t a g e p o in t s / y r ) . N = 6 1 , a d j R s q u = 0 .2 2 7 , p = v a lu e s f o r c o e f f ic ie n t s : G D P = 0 . 0 0 3 , l i t e r a c y = 0 .0 1 6 , m e a s le s = 0 .0 6 4 . C o n t r ib u t io n s c a lc u la te d a s c o e f f ic ie n t s * v a lu e s f o r e a c h c o u n t r y . B a s e = c o n s ta n t . E x p la in e d = s u m o f c o e f f ic ie n t s * c o u n t r y v a lu e s . R e s id u a l = a c t u a l – p r e d ic t e d . F in a l = a c tu a l c h a n g e o b s e r v e d ( = e x p la in e d + r e s id u a l) .

Context Rights

Program Intervention

Livelihood Health Nutrition

Worse Better

Source: based on slide by F Henry, CFNI.

Program Intervention and Context

A. In unfavourable context, program intervention for the individual has limited effect

Context Rights

Program Intervention

Livelihood Health Nutrition

Worse Better

Source: adapted from Figure 2A

Program Intervention and Context

B. In better context, program intervention for the individual has much more effect

Context Rights

Program Intervention

Livelihood Health Nutrition

Worse Better

Source: adapted from Figure 2A

Program Intervention and Context

C. In highly supportive context, improvement is endogenous and program intervention gives additional effect

Contextual Success Factorshpn/n2 -14

These apply to local programs overall, not to specific components -- eithermost appropriate activities can work, or not, depending on context.

If you cannot change critical context factors, you may have to targetelsewhere. There is no point in having a program which produces no effect(especially for predictable reasons).

Can you change the context, by policy and/or advocacy?

Factor Change it?

1. Political commitment Usually difficult in short-term

2. Women’s involvement indecisions

Usually difficult in short-term

3. Community organizations --CRUCIAL!

Essential; if do not exist must bebrought about and supported

4. Literacy, esp. women’s Can support for long-term change

5. Infrastructure for basic services Expensive but can be done

6. Empowered women Needs change in society’sattitudes, which can take a verylong time

7. ‘First call for children’ is inherent Usually difficult in short-term

8. Charismatic communityleadership

Either there or not ...

9. Poverty alleviation programs Expensive but can be done

10. No groups socially excluded(new)

Needs change in society’sattitudes, which can take a verylong time. But special programscould be done.

Factors from Jonsson (1995), see ‘How Nutrition Improves’, p 67.

Contextual Success Factorshpn/n2 -14

Figure 23

Table 4 Context in which selected community HNPs start and run.

0 worst 5 best

Country/period Period

(approx) Women’s status and education

social exclus-

ion

Community organization

literacy Level of health

And admin infrastruct

political commit-

ment

Total Minus

Pol comm

Total

Tanzania: Iringa starts

1984—90 2 4 4 3 2 5

15 20 declines 1990— 2 4 2 3 2 2 13 15 Zimbabwe: SFP starts

1981—90 2 4 5 2 2 5 15 20

declines 1990— 2 2 2 2 2 2 10 12 Bangladesh (BINP)

1997— 1 3 2 2 3 3

11 14 India (ICDS) 1975— 1 1 2 2 2 3 8 11 India (TINP) 1980—89 2 2 3 3 3 4

13 17 Indonesia: UPGK starts

1975— 2 4 3 2 2 4 13 17

declines 1990— 2 4 2 2 3 2 13 15 Philippines 1974— 4 4 3 4 3 1 19 20 Thailand 1982— 4 3 4 4 3 4 18 22 Costa Rica (Rural Hlth Prog)

1973— 4 4 4 3 4 4 19 23

Jamaica 1985— 4 4 3 4 4 4 19 23 Nicaragua 1979—90 3 2 3 3 3 4 14 18 Notes: women’s status and education can be quantified by indicators such as: adult literacy rates, females as % of males; secondary school enrollment for girls.

YEAR

00 95 90 85 80 75

%

50

40

30

20

10

0

Prevalences of underweight children,

< - 2SDs NCHS/WHO standards, 0-60 mo

Philippines

Indonesia

Thailand

Programs to improve nutrition …(meaning all those consequences for children, women, society, outlined earlier)

What?How?

Depends on …

Type of malnutrition

General (=protein-energy)

Acute (food crisis)

Micronutrient

Chronic Vitamin A (VAD)

Iron (anemia)

Iodine (I deficiencydisorders: IDDs)

By area/location

Local: Community-based and service delivery

Emergency

By socio-economic status

By biological status

Vertical

Interventions Groups affected

Source: Lancet nutrition series #3, 2008

Source: Lancet nutrition series #3, 2008

Programs: how?

Multiple (complementary) components within:

•CHNPS (community-based health and nutrition programs

•Service delivery (including IMCI)

•Central/vertical programs (e.g. fortification)

•Child Health Days

Main requirements/features for some components in localprogrammes.

ComponentSuitability of:

Community-based Service delivery,facility based

Local organization (e.g. VNWs) Antenatal care Infant feeding Growth monitoring Micronutrient supplementation Supplementary feeding Immunization, ORT Deworming Health referral NA

Day care —

Water/sanitation Microcredit —

Large scale programs

Effectiveness m&e, to build improvement and sustainability - VAC distribution - iodized salt

Trial/pilot -- Efficacy and acceptability research - VA fortification (esp. oil, otherwise with multi) - multi fortification of commercial foods - multi ‘sprinkles’ - multi supplementation esp. in pregnancy

Sequence of intervention development

Research and Development - iron fortification of staples, esp. rice - iron in salt