SCN News No 36 - UNSCN

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18 FEATURES www.unsystem.org/scn information on the current coverage of interventions to look at the additional effect of scaling-up nutrition interventions on mortality or on stunting. In paper 4, which deals with national program issues, we used the 20 countries where 80% of the stunted children live, because it was a smaller task to contact 20 countries, find out existing policies and what was being implementing on the ground. In addition to the 178 million stunted children, LNS also estimates that there are 13 millions babies born with intrauterine growth restriction and 19 million children suffering from severe wasting (Black et al 2008). Paper 1 attributes death and disease burden to undernutrition and suboptimal breastfeeding. We have tried to not only look at mortality, which has been done before, but also disability and morbidity, calculating DALYs. The concept of DALYs, which represent lost years of "healthy" life, has become a common metric for describing disease burden because it allows us to combine the years of life lost due to the conditions that cause mortality with the non-fatal sequelae, including cognitive impairment and physical disability. We can therefore compare disease burden across different conditions, including those that do not cause much mortality, such as deficiencies in iodine and iron. We estimated that nutrient and growth restriction, stunting and severe wasting combined, and without double counting, are responsible for 2 million deaths and 91 million DALYs, or 21% of the total DALYs among children under five. This represents 7% of the total global disease burden for any age group, which is the highest of any risk factor, once again highlighting the importance of undernutrition measures and the urgency of addressing undernutrition. For some of the micronutrient deficiencies, notably zinc and vitamin A, we calculated separately the disease burden. In combination, vitamin A and zinc deficiencies are the most important among the micronutrient deficiencies in contributing to the disease burden, accounting for about 10% of the global childhood DALYs. In addition, we found that iron deficiency is an important risk factor for maternal mortality, accounting for about 20% of maternal deaths each year. Suboptimal breastfeeding is another important risk factor which increases the risk of poor nutrient intake and infectious diseases and was estimated to be responsible for 1.4 million child deaths and 44 million DALYs (about 10% of global childhood DALYs). The key messages from paper 1 are that, together these risk factors account for more than one third, about 35%, of child deaths, and 11% of the total global disease burden of all ages and individuals in the world; and about 3.6 million maternal and child deaths per year. The very high mortality and disease burden resulting from nutrition-related factors make a compelling case for the urgent implementation of proven interventions. Regarding the longer-term consequences, paper 2 in the series presents extensive analysis that demonstrates how nutrition-related damage suffered in early life leads to permanent impairment. Undernourished children are more likely to become short adults and to give birth to smaller babies, thus there is a second generation effect. Moreover, strong evidence exists that links stunting to cognitive development, school performance and educational achievement. Poor foetal growth or stunting in the first two years of life leads to reduced economic productivity in adulthood. Paper 2 found that a child's height for age is the best predictor for human capital. We also looked extensively at the relationship between foetal and early childhood undernutrition and later chronic disease and have found some very strong relationships. Children whose early growth is restricted and gain weight rapidly later are more likely to have high blood pressure, diabetes and other metabolic conditions. A key finding from these analyses is that even with a low birth weight or IUGR the weight gained rapidly in the first two years of life is actually not harmful, but rather beneficial. This gives important indications that childhood nutritional interventions need to be directed to the first two years of life. Evidence-based nutrition interventions Paper 3 presents a systematic review of efficacy or effectiveness of 45 possible interventions that affect maternal and child undernutrition and nutrition-related outcomes. These potential ranged widely from the more specific interventions on breastfeeding promotion, complementary feeding promotion strategies with or without provision of food supplements and micronutrient interventions, to broader ones on supporting strategies for improving family and community nutrition and disease burden reduction and of course interventions for the treatment of severe acute malnutrition. SCN NEWS # 36 back to contents
www.unsystem.org/scn FEATURES 19 Table 1 summarizes the various interventions with demonstrated impact on maternal and child undernutrition in all countries. These are interventions that have sufficient evidence to be implemented in all countries to improve maternal and birth outcomes and nutrition of newborns, infants and young children. Promotion of breastfeeding and complementary feeding comes out as a very important intervention, along with micronutrients provided in pregnancy and maternal protein-energy supplementation. Importantly, for each of the conditions contributing to nutrition-related disability and death there are already highly effective interventions available. Other interventions were found to be appropriate in certain situational contexts, such as in malaria endemic areas or areas with high deficiency rates of particular micronutrients. Modelling the impact of nutrition interventions For the purpose of modelling the effect of these interventions, we developed a cohort model with data from the 36 high burden countries. Taking into account existing intervention coverage, we calculated the potential effect of scaling-up the proven nutrition and health-related interventions to 70%, 90% and 99% to see how much additional disease burden (DALYs) Figure 1: Cohort model for mortality and stunting or mortality (deaths) could be averted. The used to model the effectiveness of interventions major aspect of the model is a cohort structure that follows children from birth to 36 months, with death, stunting and no stunting as potential outcomes. Figure 1 shows the sort of information generated by the model and what happens between birth and 36 months of age. Starting at birth and then progressively looking over time, by 36 months of age about 9% of children have died (mortality showed in top part of figure) and of those who survive over half (58%) are stunted (stunting 0 12 24 36 Age in months showed in middle part of figure). This Died Stunted cohort was mainly used for the preventive Not stunted interventions, whereas for the therapeutic treatment of severe acute malnutrition we modelled separately to calculate the Table 3: Reductions in child mortality at full coverage number of deaths that could be averted. Table 3 lists some of the results from the modelling. For reductions in child mortality at full coverage of the evidence-based interventions, breastfeeding promotion is expected to have high impact. The calculations are based on the best available evidence for how well breastfeeding promotion programmes have changed practices. Individual peer counselling, for example, has been rather successful in changing breastfeeding practices towards more exclusive breastfeeding. Supplementation with vitamin A and of zinc has important preventive effects on mortality. Complementary feeding promotion and supplementation in food insecure areas % of birth cohort 0 20 40 60 80 100 Child interventions • Breastfeeding promotion – 9.1% • Vitamin A supplementation – 7.2% • Zinc supplementation – 3.6% • Treatment of severe malnutrition – 2.2% • Comp. feeding promotion/supplement. – 1.5% Maternal interventions • Energy/protein supplementation – 2.9% • Intermittent preventive malaria treatment – 1.9% • Multiple micronutrients – 1.6% Table 4: Other intervention effects at full coverage • Zinc supplementation – 17% reduction in stunting • Complementary feeding promotion/supplementation– 15 % reduction in stunting • Iron and folate supplementation – 20% reduction in maternal deaths • Hygiene promotion – 2.4% reduction in stunting back to contents SCN NEWS # 36
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