Nutrition Publication

NNIW78 - International Nutrition: Achieving Millennium Goals and Beyond

Editor(s): R. Black, A. Singhal, R. Uauy. 78

The UN Millennium Development Goals Report, 2012 says: “Despite clear evidence of the disastrous consequences of childhood nutritional deprivation in the short and long terms, nutritional health remains a low priority. It is time for nutrition to be placed higher on the development agenda.The Nestlé Nutrition Institute 78th NNI workshop “International nutrition: achieving millennium goals and beyond” on improving young woman and child nutrition and health was held in Muscat, Oman on the 19-22 of March 2013.Throughout the three-day workshop KOLs participated in discussions on the nutritional scenarios around the world and saw evidence of field interventions to combat maternal and child under and over nutrition and micronutrient deficiencies. The chairpersons – Prof. R.Uauy, Prof. B.Black and Prof. A.Singhal organized an excellent scientific workshop program with the purpose to cover the issues related to nutrition in the developing and developed world.

Related Articles

Addressing the Double Burden of Malnutrition with a Common Agenda

Author(s): R. Uauy, M. Garmendia, C. Corvalán

Addressing malnutrition in all its forms represents an integrated agenda addressing the root causes of malnutrition at all stages of the life course. The issue is not about choosing between addressing undernutrition in the poor versus overnutrition in the affluent. We must recognize that the interventions required to address stunting are different from those needed to reduce underweight and wasting. In most developing regions, there is a coexistence between underweight and stunting in infants and children, while in the adult population it may be overweight and stunting. Malnutrition in all its forms refers to both underweight and overweight. Underweight is defined by a low weight-for-age, a child is underweight because of wasting (low weight-for-height) or stunting (low length-for-age). Stunting refers to low height-for-age independent of their weight-for-age, some stunted children may have excess weight for their stature length. Overweight is excess weight-forlength/- height or high-BMI-for-age. The prevention of nutrition-related chronic diseases is a life-long process that starts in fetal life and continues throughout infancy and later stages of life. It requires promoting healthy diets and active living at each stage. The agenda requires that we tackle malnutrition in all its forms.

Country-Level Action to Improve Nutrition and Health The Case of Chile in the Last Century

Author(s): J. Jimenez

Preference for mother and child social protection is a constant in public policies all around the world. Most of the basic strategies are known and have been described, proven on its efficacy and cost-effectiveness several times in different settings in the last 100 years. But from knowledge to action and from action to impact, there has been a variable and dramatic gap which can be mended with other policy tools. Beyond technical considerations, conviction, commitment and mystique are in my view and experience those critical factors. The other issue is close relation between academia, policy making, regular politics and public opinion. 

Fetal Growth Restriction and Preterm as Determinants of Child Growth in the First Two Years and Potential Interventions

Author(s): P. Christian

In 2010, 171 million children under 5 years old were estimated to be stunted globally, with 98% being from low- and middle-income countries. Low birthweight including fetal growth restriction is also common in these regions and may contribute to childhood undernutrition. As part of the Child Health Reference Group (CHERG) and using 14 longitudinal birth cohorts and anthropometric measurements taken at 24 months of age, pooled odds ratios (ORs) were calculated to examine the relationship between small for gestational age (SGA) and preterm birth and subsequent stunting and wasting in children. Relative to term adequate size for gestational age (AGA), the OR (95% confidence interval) for stunting associated with AGA-preterm, SGA-term and SGA-preterm was 1.94 (1.59– 2.36), 2.82 (2.40–3.32) and 4.98 (3.79–6.55), respectively. A similar magnitude of risk was also observed for wasting and underweight. This analysis indicates that childhood undernutrition may have its origins, in part, in the fetal period, suggesting a need to intervene during an earlier life stage during pregnancy and even preconceptionally, but also putting emphasis on maternal nutrition in general and adolescent nutrition. Interventions shown to impact fetal growth include antenatal supplementation with balanced calorie and protein, iron-folic acid, and multiple micronutrients. Nutrition-sensitive interventions such as delaying the first pregnancy, antimalarials and smoking cessation in some settings may be important.

Global Distribution and Disease Burden Related to Micronutrient Deficiencies

Author(s): R. Black

Micronutrients are vitamins and minerals that are essential for human life and health. Deficiencies in these micronutrients are common because of poor quality diets and frequent infectious diseases in low- and middle-income countries. The high prevalence of deficiencies and their important adverse consequences on mortality, morbidity and disability result in a substantial disease burden. In particular, deficiencies of vitamin A and zinc increase the risk of child mortality, and zinc deficiency increases infectious morbidity and reduces linear growth as well. Deficiencies of iodine and iron are significant primarily for their effects on development and cognition and consequent disabilities. Programs targeting each of these micronutrients are underway and, particularly for vitamin A and iodine,  have some success. Greater efforts to address these and the full set of micronutrients are needed to reduce their global burden of diseases.

Global, Regional and Country Trends in Underweight and Stunting as Indicators of Nutrition and Health of Populations

Author(s): L.M. Neufeld, S.J.M. Osendarp

Stunting and wasting provide indicators of different nutritional deficiency problems, the causes of which are well established. Underweight based on weight-for-age cannot distinguish between these two and is therefore not useful to target programs and has limited value for tracking progress. Stunting reduces later school attainment and income as adults and increases the risk of obesity and noncommunicable diseases in later life. Globally, the estimated number of stunted children is decreasing, but is not on track to meet the goal of 100 million by 2025 (165 million), and there has been little change in the number of children suffering from wasting since 2004. Stunting and wasting provide excellent  indicators of inequity. For example, from 1990 to 2010, the number of stunted children in Asia declined from 188.7 to 98.4 million, while in sub-Saharan Africa there was essentially no change in prevalence, and the number of stunted children increased from 45.7 to 55.8 million. Recent global development movements are recognizing the need for robust measures of trends in nutritional status of children, particularly during the critical first years of life. Such measures are needed to track progress and improve accountability, and should be aspirational to mobilize sufficient investment in nutrition.

How Can Agricultural Interventions Contribute in Improving Nutrition Health and Achieving the MDGs in Least-Developed Countries?

Author(s): A. Dorward

There are strong conceptual linkages between agricultural development and nutrition improvements which may be categorized into three main pathways: the development, own-production and market pathways. Evidence on the efficacy of these pathways is mixed with some strong, some negative and some weak impacts. These findings reflect both the importance of agriculture for nutrition and the conditionality of that importance on contextual factors. They are also the result of insufficient high-quality empirical researchinvestigating these linkages. The most effective ‘pathways’ and interventions linking agricultural change to improved nutritional outcomes change with economic growth and development, with declining importance of the development and own-production pathways and increasing importance of the market pathway. Substantial challenges in operationalizing agricultural-nutrition linkages need to be overcome to better exploit potential opportunities.

Interventions to Address Maternal and Childhood Undernutrition: Current Evidence

Author(s): Z. Bhutta

The global burden of undernutrition remains high with little evidence of change in many countries. We reviewed the evidence of the potential nutritional interventions and estimated their effect on nutrition-related outcomes of women and children. Among the maternal interventions, daily iron supplementation results in a 69% reduction in incidence of anemia, 20% in incidence of low birthweight (LBW) and improves mean birthweight. MMN supplementation during pregnancy has been shown to significantly decrease the number of LBW infants by 14% and small for gestational age (SGA) by 13%. Balanced protein-energy supplementation reduces the incidence of SGA by 32% and risk of stillbirths by 38%. Antimalarials when given to pregnant women increase the mean birthweight significantly and were associated with a 43% reduction in LBW and severe antenatal anemia by 38%. Among the neonatal and child interventions, educational/counseling interventions increased exclusive breastfeeding by 43% at 4–6 weeks and 137% at 6 months. Vitamin A supplementation (VAS) reduces all-cause mortality by 24% and results in a 14% reduction in the risk of infant mortality at 6 months. Intermittent iron supplementation in children reduces the risk of anemia by 49% and iron deficiency by 76%, and significantly improves hemoglobin and ferritin concentration. Preventive zinc supplementation in populations at risk of zinc deficiency decreases morbidity from childhood diarrhea and acute lower respiratory infections, and increases linear growth and weight gain among infants and young children. Among the supportive interventions, hand washing with soap significantly reduces diarrhea morbidity by 48%, though it depends on access to water. The effect of water treatment on diarrhea morbidity also appears similarly large with a 17% reduction. Recent research has established linkages of preconception interventions with improved maternal, perinatal and neonatal health outcomes, and it has been suggested that several proven interventions recommended during pregnancy may be even more effective if implemented before conception. These proven interventions, if scaled up have the potential to reduce the global burden of undernutrition substantially.

Long-Term Consequences of Nutrition and Growth in Early Childhood and Possible Preventive Interventions

Maternal nutritional deficiencies and excesses during pregnancy, and faster infant weight gain in the first 2 years of life are associated with increased risk of noncommunicable diseases (NCDs) in adulthood. The first 1,000 days of life (from conception until the child reaches age 2 years) represent a vulnerable period for programming of NCD risk, and are an important target for prevention of adult disease. This paper takes a developmental perspective to identify periconception, pregnancy, and infancy nutritional stressors, and to discuss mechanisms through which they influence later disease risk with the goal of informing age-specific interventions. Low- and middle-income countries need to address the dual burden of under- and overnutrition by implementing interventions to promote growth and enhance survival and intellectual development without increasing chronic disease risk. In the absence of good evidence from long-term follow-up of early life interventions, current recommendations for early life prevention of adult disease presume that interventions designed to optimize pregnancy outcomes and promote healthy infant growth and development will also reduce chronic disease risk. These include an emphasis on optimizing maternal nutrition prior to pregnancy, micronutrient adequacy in the preconception period and during pregnancy, promotion of breastfeeding and high-quality complementary foods, and prevention of obesity in childhood and adolescence.

Maternal Nutrition Interventions to Improve Maternal, Newborn and Child Health Outcomes

Author(s): U. Ramakrishnan, B. Imhoff-Kunsch, R. Martorell

Maternal undernutrition affects a large proportion of women in many developing countries, but has received little attention as an important determinant of poor maternal, newborn, and child health (MNCH) outcomes such as intrauterine growth restriction, preterm birth (PTB), and maternal and infant morbidity and mortality. We recently evaluated  the scientific evidence on the effects of maternal nutrition interventions on MNCH outcomes as part of a project funded by the Gates Foundation to identify critical knowledge gaps and priority research needs. A standardized tool was used for study data abstraction, and the effect of nutrition interventions during pregnancy or of factors such as interpregnancy interval on MNCH outcomes was assessed by meta-analysis, when possible. Several nutrient interventions provided during pregnancy have beneficial effects on MNCH outcomes, but are not widely adopted. For example, prenatal calcium supplementation decreases the risk of PTB and increases birthweight; prenatal zinc, omega-3 fatty acids and multiple micronutrient supplements reduce the risk of PTB (<37 weeks), early PTB (<34 weeks) and low birthweight (LBW), respectively. Among currently implemented interventions, balanced protein-energy and iron-folic acid supplementation during pregnancy significantly reduce the risk of LBW by 20–30% in controlled settings, but variable programmatic experiences have led to questionable effectiveness. Early age at pregnancy and short interpregnancy intervals were also associated with increased risk of PTB, LBW and neonatal death, but major gaps remain on the role of women’s nutrition before and during early pregnancy and nutrition education and counseling. These findings emphasize the need to examine the benefits of improving maternal nutrition before and during pregnancy both in research and program delivery.

Nutrition and Chronic Disease: Lessons from the Developing and Developed World

Author(s): A. Prentice

Many features of human susceptibility to chronic noncommunicable diseases can be mapped onto the framework of the match/mismatch hypothesis. From an evolutionary perspective, it is highly likely that the human genome has been under selective pressure to survive and reproduce against a background of seasonal food shortages and frequent episodic famines, leading to the attractive, but unproven, concept of ‘a thrifty genotype made deleterious by famine’. From an ontogeny perspective, it has been clearly demonstrated that fetal undernutrition leads to a thrifty phenotype that enhances metabolic risk if the individual is later exposed to an energy-abundant environment. Data from developing and rapidly emerging countries permit insights into both of these pathways. Many populations are rapidly emerging from conditions broadly representative of human history over the past 600 or so generations (i.e. since the dawn of agriculture) and are transitioning within very few generations to a state of dietary abundance and low physical activity. And within this framework, many individuals make an even more rapid personal transition from the womb of a malnourished mother to a state of affluence. These journeys provide exceptional opportunities to interrogate thrifty genotype/phenotype theories, but such prospects are frequently impaired by a lack of robust data.

Obesity and the Metabolic Syndrome in Developing Countries: Focus on South Asians

Author(s): A. Misra

With improvement in the economic situation, an increasing prevalence of obesity and the metabolic syndrome is seen in developing countries in South Asia. Particularly vulnerable population groups include women and children, and intra-country and inter-country migrants. The main causes are increasing urbanization, nutrition transition, reduced physical activity, and genetic predisposition. Some evidence suggests that widely prevalent perinatal undernutrition and childhood ‘catch-up’ obesity may play a role in adult-onset metabolic syndrome and type 2 diabetes. Data show that atherogenic dyslipidemia, glucose intolerance, thrombotic tendency, subclinical inflammation, and endothelial dysfunction are higher in South Asians than white Caucasians. Many of these manifestations are more severe even at an early age in South Asians than white Caucasians. Metabolic and cardiovascular risks in South Asians are also heightened by their higher body fat, truncal subcutaneous fat, intra-abdominal fat, and ectopic fat deposition (liver fat, muscle fat, etc.). Further, cardiovascular risk cluster manifests at a lower level of adiposity and abdominal obesity. The cutoffs of body mass index and waist circumference for defining obesity and abdominal obesity, respectively, have been lowered for Asians, and same has been endorsed for South Asians in the UK. The economic cost of obesity and related diseases in developing countries, having meager health budget, is enormous. Increasing awareness of these noncommunicable diseases and how to prevent them should be focus of population-wide prevention strategies in South Asian developing countries. Community intervention programs focusing on increased physical activity and healthier food options for schoolchildren are urgently required. Data from such a major intervention program conducted by us on adolescent urban schoolchildren in north India (project MARG) have shown encouraging results and could serve as a model for initiating such programs in other South Asian developing countries.

Predicting the Health Effects of Switching Infant Feeding Practices for Use in Decision-Making

Author(s): B. Yarnoff, B. Allaire, P. Detzel

Research has been plentiful to show pediatricians and public health practitioners the importance of exclusive breastfeeding for infant health. However, this past research is lacking in a few ways that are important for pediatricians and public health practitioners: it rarely examines broad geographies, and so cannot be generalized for different countries, it does not quantify the predicted effects of infant feeding, and it does not examine the effects of a range of feeding practices on infant health, instead focusing solely on exclusive breastfeeding. The present research simulates the effect on infant health of switching between a range of feeding practices using data from many countries. The results provide quantified estimates of the effect of switching between specific feeding practices such as exclusive breastfeeding, breastfeeding supplemented with milk liquids, or breastfeeding supplemented with solid foods and nonmilk liquids, as well as others. These quantified estimates of the effect of switching infant feeding practices can be used by pediatricians to motivate individual decisions about infant feeding and by public health practitioners and policymakers to motivate infant feeding programs and policy. Through these channels, they can hopefully play a role in improving infant health.

Preventing Atopy and Allergic Disease

Author(s): R. Heine

Due to the recent exponential increase in food allergies and atopic disorders, effective allergy prevention has become a public health priority in many developed regions. Important preventive strategies include the promotion of breastfeeding and vaginal deliveries, judicious use of perinatal antibiotics, as well as the avoidance of maternal tobacco smoking. Breastfeeding for at least 6 months and introduction of complementary solids from 4–6 months are generally recommended. Complex oligosaccharides in breast milk support the establishment of bifidobacteria in the neonatal gut which stimulate regulatory T lymphocyte responses and enhance tolerance development. Maternal elimination diets during pregnancy or lactation are not effective in preventing allergies. If exclusive breastfeeding is not possible, (supplemental) feeding with a partially hydrolyzed whey-based formula or extensively hydrolyzed casein-based formula may reduce the risk of cow’s milk allergy and atopic dermatitis in infants with a family history of atopy. By contrast, asthma and allergic rhinitis at 4–6 years of age are not prevented by this approach. Soy formula and amino acid-based formula have no proven role in allergy prevention. Perinatal supplementation with probiotics and/or prebiotics may reduce the risk of atopic dermatitis, but no reliable effect on the prevention of food allergy or respiratory allergies has so far been found. A randomized trial on maternal fish oil supplementation during pregnancy found that atopic dermatitis and egg sensitization in the first year of life were significantly reduced, but no preventive effect for food allergies was demonstrated. The role of vitamin D deficiency or excess as a risk factor for food allergy and atopic disorders requires further study.

The Global Epidemic of Noncommunicable Disease: The Role of Early-Life Factors

Author(s): A. Singhal

The rapid increase in prevalence of noncommunicable diseases (NCDs) is probably the most important global health problem of the 21st century. Already in every region except Africa, NCDs account for greater mortality than communicable, maternal, perinatal and nutritional conditions combined. Although modifiable lifestyle behaviors in adult life are the main risk factors, substantial evidence now suggests that factors in early life also have a major role in the development of NCDs. For instance, breastfeeding and a slower pattern of infant weight gain have been shown to reduce the risk of obesity, cardiovascular disease and diabetes in both low-income and high-income countries. The mechanisms involved are poorly understood, but include epigenetic changes and resetting of endocrine systems that affect energy metabolism and appetite. These early life factors may interact with and exacerbate the detrimental effects of a sedentary lifestyle and energy-dense diets later in life. As a consequence, the impact of early-life factors on long-term health may be particularly important in low- and middle-income countries, which face the fastest increases in urbanization and greatest changes to lifestyle. Strategies to optimize infant nutrition could therefore make a major contribution to stemming the current global epidemic of NCD.