NUTRITION IN THE LIFESPAN # 4C
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Lalita BhattacharjeeNutritionist
National Food Policy Capacity Strengthening Programme Food and Agriculture Organization of the United Nations
Bangladesh Presented on 2 July 2011
at the Training Workshop on “Food Security Concepts, Basic Facts
and Measurement Issues” 25 June to 7 July 2011
NUTRITION IN THE LIFESPAN # 4C
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Introduction Nutrition through the life stages Dietary energy and nutritional requirements in: Infancy - birth to 1 year Childhood and adolescence Pregnancy and lactation Intergenerational effects Diet, energy and nutritional requirements in
adulthood Nutrition during ageing and the elderly Operational Plan Indicators Life cycle approach Conclusion
OUTLINE
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Diets in all cultural variety define to a large extent people’s health, growth and development
Advances in research, expansion of knowledge in prevention and control of chronic diseases
Return to the concept of basic life course – continuity of human life from fetus to old age
Need to address both undernutrition and overnutrition
Introduction
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Nutritional status is internationally recognized as an indicator of national development
Nutrition is both an input and an output/come of the development process
A well-nourished population is essential for productive work force and development◦ people need food, health and care to be well-nourished
Two processes: ◦ on the one hand food security policies ◦ on the other sustainable livelihoods, right to food and
nutrition policies …with different partners The food, agriculture and health sectors is responsible for
food and nutrition security
Nutrition vs Food Security
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MATERNAL, CHILD AND HOUSEHOLD NUTRITION
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Intra uterine growth retardation (IUGR)
Premature delivery of a normal growth for gestational age fetus
Overnutrition in utero
Intergenerational factors
Fetal development and maternal environment : Relevant factors
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Dietary, energy and nutritional requirements
All neonates typically lose some weight after birth
Pre term infants are born with more extra cellular water than term infants and thus lose more weight than term infants
Post natal loss should not be excessive. Loss of 15-20% of birth weight can lead to
dehydration – inadequate fluid intake or tissue wasting from poor energy intake
Nutrition through the life stages : Infancy – Birth to 1 year
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Child growth at different ages
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Nutrition through the life stages : Infancy – Birth to 1 yearWhat defines
Infancy?The first year of life.Why are the nutrientneeds of an infant so high?Infants grow ataccelerated rate: double birth weight by 6 months; triples by 12months of age
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Exclusive breast fedding Predominant Feeding No breast feeding
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
5.00%
2.34%
1.90%
4.37%
Mor
talit
y R
ate
Relationship of Breastfeeding Practices with Mortality of (0-12) months children in
Bangladesh
Source:Arifeen et al, 2001
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The new era of Breastfeeding Growth chart of 21 century
New International Child Growth Standards for infants and young children released on 27 April 2006 ⇛ A community based study “The Multicentre Growth Reference Study (MGRS)’’ undertaken by WHO & United Nations University ⇛ More than 8000 children followed after every 3 months from Brazil, Ghana, India, Norway, Oman and USA
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What are the nutrient needs of an infant and why are they so high?
Monitoring infant growth:
◦ Infants not receiving adequate nutrition may have difficulty reaching milestones
◦ Failure to thrive (FTT): delayed in physical growth or size or does not gain enough weight
◦ Growth charts track physical development. Head circumference, length, weight, and weight for
length measures are used to assess growth
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What are the nutrient needs of an infant and why are they so high?
Infants have specific calorie, iron, and other nutrient needs.
108 calories/kg of body weight for first 6 months 9.1 g protein/day first 6 months, 11 g/day
second 6 months Fat should not be limited. Vitamin K injection needed due to sterile gut Iron-enriched cereals/home based foods should
be introduced at 6 months.
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Infant Nutrition: Solid Foods Complementary foods
◦ Not recommended to give any solid foods before 6 months
When to beginAbout 6 months of ageIron and zinc stores depletedLook for physical signsLoss of extrusion reflex
Nutrient-dense foods
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When Are Solid Foods Safe?Solid foods should be introducedgradually to make sure child isn’t allergic or
intolerant◦ One new food per week◦ Rice cereal is great first food: least allergy-causing◦ Other grains, then vegetables, fruits over a period
of monthsHomemade or store-bought baby food?
◦ Homemade is cheaper, but can also find high-quality store-bought foods without added sugar, salt, preservatives
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The Global Strategy of IYCF
Implementation of comprehensive policies by the Government
Full support for two years of breastfeeding or more
Promotion of timely, adequate, safe and appropriate complementary feeding
Guidance on IYCF in especially difficult circumstances,
Legislation or suitable measures giving effect to the International Code
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Percent children underweight1980-2007
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
0
10
20
30
40
50
60
70
80Africa
Asia
Bangladesh
India
Nepal
Pakistan
Sri Lanka
YearPrev
alen
ce o
f und
erw
eigh
t (%
of c
hild
ren
unde
r fiv
e)
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Country and yr
H/A% < - 2
SD
H/A % < - 3
SD
W/H % < - 2
SD
W/H % < - 3 SD
W/A % < - 2SD
W/A % < - 3SD
Bangladesh 2007 MF
43.742.7
16.515.8
18.416.5
3.32.5
39.942.1
11.4 12.1
India 2005 -06 MF
48.140.0
23.723.4
20.5 19.1
6.86.1
41.9 43.1
15.316.4
Nepal 2006 MF
49.049.6
19.520.8
12.912.3
3.12.2
37.5 39.7
10.111.2
Nutritional status of children U5
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Nutrition and Poverty: Prevalence of Underweight by Wealth Quintiles (Children <5 yrs, below -2SD)
Region Country Lowest 2nd 3rd 4th Highest
South Asia
Bangladesh 59 53 45 43 30 India 61 54 49 39 26
Pakistan 54 47 43 37 26Africa Benin 29 30 23 20 10 Burkina Faso 42 40 41 39 22 Ethiopia 49 51 51 45 37 Mozambique 31 28 26 19 9 Rwanda 27 30 28 24 14 Tanzania 25 26 22 20 12 Uganda 27 26 25 19 12
Source: Gwatkin et al, Country Reports on HNP and Poverty: Socio-Economic Differences in Health, Nutrition, and Population, April 2007
Is Malnutrition in South Asia Really Worse than in Africa?
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Quintile H/A % < - 2SD
H/A % < - 3 SD
W/H % < - 2 SD
W/H % < -3 SD
W/A % < - 2SD
W/A % < - 3 SD
Lowest 54.0 23.2 20.8 3.8 50.5 15.1
Second 50.7 20.4 17.8 2.8 45.9 15.8
Middle 42.0 15.2 16.9 2.6 41.0 11.2
Fourth 38.7 11.8 17.6 2.8 38.1 8.9
Highest 26.3 13.2 13.2 2.0 26.0 6.5
Nutritional status of children by wealth quintile in Bangladesh
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Age group Category Body weight kg
Kcal/d Kcal/kg/d
Infants 0-6 mo6-12 mo
5.48.4
500670
9280
Children 1-3 y4-6 y7-9 y
12.918.125.1
106013501690
827567
Boys 10-12 y 34.3 2190 64Girls 10-12 y 35.0 2010 57Boys 13-15 y 47.6 2750 58Girls 13-15 y 46.6 2330 50Boys 16-17 y 55.4 3020 55Girls 16-17 y 52.1 2440 47
Energy requirements at different ages
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Association between low growth in childhood and increased risk of CHD, irrespective of size at birth
Postnatal factors shaping disease risk Growth rates of infants in Bangladesh (most
of whom had chronic IUUN and were breast fed, were similar to growth rates of breast fed infants in industrialized countries
Catch up growth was limited and weight at 1 yr was a function of birth weight
Childhood and adolescence
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LBW babies have characteristic poor muscle but high fat preservation ( so called thin fat babies)
This phenotype persists throughout post natal life and is associated with increased central adiposity in childhood that is linked to ↑ risk of raised BP and disease
Association between LBW and high BP and BMI – importance of weight gain after birth
Relative weight in adulthood and weight gain associated with ↑ risk of cancers
Height serves partly as an indicator of socio economic and nutritional status in childhood (energy and protein intake)
Childhood and adolescence
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Secondary sexual characteristics emerge, with onset of menarche (periods) in girls and semenarche (production of semen) in boys
Physical developments are accompanied by marked changes in psychological and emotional make up, characteristic of ‘teenage’ behaviour
Adolescence begins approx 2 years earlier in girls than boys, with acceleration of growth of muscle in boys and deposition of adipose tissue in girls
According to WHO, 10 to 18 y is the period of adolescence
Adolescence: Physical changes
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Adolescent boys experience rapid muscular growth and engage in more physical activities than girls so they need more energy foods
Adolescent girls, because of menstruation, need more iron than boys
Iron is essential for building and maintaining blood supplies ad giving the blood its red colour
Girls should take more iron rich foods such as liver, egg yolk, lean meat, green leafy vegetables, dried beans, dried fruits and unpolished rice and whole wheat
Adolescence: Physical changes
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Age group
BW kg Gain BW kg/y
Basal loss mg/d
Blood volume mg/d
Muscle massMg/d
StoreMg/d
Blood lossMg/d
Total reqmtMg/d
10-12 y
Boys
Girls
34.3
35.0
3.5
3.70.49 0.27 0.13 0.16
-----
0.28
1.05
1.3313-15 y
Boys Girls
47.646.6
4.21.7
0.660.65
0.390.13
0.150.06
0.400.15
----0.37
1.601.36
16-17 y
BoysGirls
55.452.1
1.5 0.780.73
0.14----
0.05----
0.400.15
----0.42
1.371.30
Iron requirements during adolescence
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Development of risk factors Tracking of risk factors (in terms of prevention)
Development of healthy/unhealthy habits that tend to stay throughout life (physical inactivity)
Older adolescents (habitual alcohol, tobacco use associated with risks of ↑ BP and related risks
Syndrome X ( physiological disturbances, hyper insulinemia, impaired GT, HT, ↑ TG and ↓ HDL
Adolescence : Critical aspects
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Weight gain during pregnancy is an indicator of nutritional status of pregnant women
A weight gain of 11 -13 kg during the pregnancy term is ideal
According to various studies, weight gain during pregnancy in Bangladeshi mothers is only 7-9 kg indicative of poor nutritional status of the mother and poor growth of the fetus
The fetus is born with LBW ( < 2.5kg) Over a third (36%) of babies in Bangladesh are
born with LBW
Weight gain during pregnancy
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Rate of tissue
deposition
1st trimester
(g/d)
2nd trimester
(g/d)
3rd trimester
(g/d)
Total deposited
(g)
Weight gain 17 60 54 12,000 Protein deposited
0 1.3 5.1 597
Fat deposited
5.2 18.9 16.9 3741
Average of 2nd and 3rd trimesters
12 kg increase 375 kcal
10 kg increase 310 kcal
Additional energy cost of pregnancy with gestational weight
gain of 12 kg
NIN/ICMR (2010) Nutrient requirements and RDA for Indians
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Lactation is the period when the mother feeds her baby through the breast.
On an average 600-800 ml/d milk is produced by a nursing mother
Approximately 1kcal of energy is needed to produce 1 ml of milk
Malnutrition during pregnancy is likely to continue after birth of the baby if the mother is poorly nourished; a malnourished mother cannot breast her baby adequately
Malnutrition affects the volume of milk produced if not its quality
LACTATION
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Age group Category Body weight (kg)
RequirementKcal/d kcal/kg/d
Man Sedentary 60 2320 39Moderate 60 2730 46
Heavy 60 3490 58Woman Sedentary 55 1900 35
Moderate 55 2230 41Heavy 55 2850 52
Pregnant 55+ GWG + 350Lactation 55 + WG + 600
+ 520
Energy requirements at different ages
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Women of reproductive age:
The reproductive age in Bangladeshi mothers is considered as 15 to 44 years
CED in women of reproductive age is measured by height and BMI
Height < 145 cm and BMI < 18.5 kg/m² is indicative of chronic CED
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The “Window of Opportunity” for Improving Nutrition is very small…pre-pregnancy until 18-24 months of age
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-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
0.00
0.25
0.50
Latin America and Caribbean Africa
Asia
Age (months)
Wei
ght f
or a
ge Z
-sco
re (N
CH
S)
Repositioning Nutrition, 2006
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New Evidence shows the “window of opportunity” may be even smaller than we had anticipated…with a larger part of the damage happening before birth…
-2.5-2.25
-2-1.75-1.5
-1.25-1
-0.75-0.5
-0.250
0.250.5
0.751
1.251.5
Age (months)
Z-s
core
s (W
HO
)
EURO PAHOEMRO SEAROAFRO
Source: Victora CG, et al. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print)
Mean height for age z-scores by age relative to the new WHO reference By region (0-59 months)
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Women’s status and reductions in child undernutrition
Health en-vironment
19%
National food
availabil-ity
26%
Women's status12%
Women's education
43%
Chart Title
Contributions to reductions in child malnutrition, 1970-95
Source: Smith and Haddad 2000
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To what extent risk factors continue to influence development of CD
To what extent will modifying such risk factors make a difference in the emergence of disease
What is the role of risk factor reduction and modification in secondary prevention and the treatment of those with disease
Adult phase of life –disease expressed, critical time for preventive reduction of risk factors and increasing effective treatment
Adulthood : Risk factors
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Most chronic diseases will be manifested in later stages of life
Absolute benefits in changing risk factors and adopting health promoting behaviours (exercise and healthy diets)
Maximize health by avoiding /delaying preventable disability
Along with societal and disease transitions, major demographic shifts
Older people defined above 60 y Average life expectancy increased from middle of last
century Majority of elderly will be living in the developing world
Ageing and older people :Critical aspects
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Disease Eating poorly Tooth loss/Mouth pain Economic hardship Reduced social contact Multiple medicines Involuntary weight loss/gain Needs assistance in self care Elder years above age 80
DETERMINE : CHECK LIST
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Reduced need for calories More prone to disease due to lowered food
intake, physical activity and resistance to infection
Good food habits and regular exercise minimize the ill effects of ageing
Need for more calcium, iron, zinc, VA and anti oxidants to prevent age related diseases
Note: Variety of nutrient rich foods, match food intake with physical activity, eat food in many divided portions/d, avoid fried, salty and spicy foods and exercise regularly
Elderly should have a nutrient rich diet to keep fit and active
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Policy implications from the new WHO growth references ++ recent evidence• Confirms importance of first 2 years of life as a critical window within which child
growth is most sensitive to environmentally modifiable factors
• Monitoring length/height (in addition to weight) seems essential because faltering patterns are clearly different for HAZ and WAZ, and short stature is associated with deleterious long-term outcomes
• Reveal a much greater problem of undernutrition during the first 6 months of life than previously understood (shorter “window of opportunity”) with possibly even higher levels of intrauterine growth retardation emphasizing the need for even greater need for prenatal and early-life interventions, including preventing low birth weight and promoting appropriate infant feeding practices
• Suggests that BMI gain after 6 months of age increases adiposity but not height at 5years – hence potentially negative implications for NCDs in adulthood
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Relation Between Low Birth Weight and GDP per capita is not linear
Percent children LBW
Slide courtesy of John Newman, SAR (2010)Source: WB World Development Indicators, Latest available data for each country, GDP PC PPP, constant int’l 2005 $
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Malnutrition Poverty GDP losses 2-3%
Leads to a >10% potential reduction in lifetime earnings for each malnourished individual
Malnutrition (stunting) in early years linked to a 4.6 cm loss of height in adolescence 0.7 grades loss of schooling 7 month delay in starting school
Repositioning Nutrition, 2006
(Improved nutrition can be a driver of economic growth)
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Ranges of nutrient intake goals (WHO/FAO, 2003)
Dietary factor Goal (% of total energy )Total fat 15-30%
Saturated fat < 10%PUFA 6-10%
Trans fatty acids < 1%Total CHO 55 -75%
Free sugars 10%Protein 10-15%
Cholesterol <300mg/dNa Cl <5g/d
Fruits and vegetables at least 400 g/dTotal dietary fibre From foods (40g/d)
Non starch polysaccharides (NSP) From foods (whole grains, F&V) 20g/d
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Dietary guidelines :Healthy food pyramid
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Three child well being outcomes : Mothers and children are well nourished
(measured by rates of stunting and anemia) Mothers and children are protected from
infection and disease (measured by rates of malaria/illness, care seeking for treatment of diarrhea and ARI and immunization rates)
Mothers and children access essential health services (measured by rate of skilled attendance at birth and antenatal coverage)
Health and nutritional goals
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Objective Baseline Target 2016↓ in prevalence of LBW ( < 2.5
kg)22% (SOWC, 2009) 15%
↓ in the prevalence of UW (WAZ < -2 Z scores ) in children < 5 y
41% (BDHS, 2007) 34%
↓ in prevalence of stunting (HAZ < -2 Z scores
43% ( BDHS, 2007) 38%
↓ in prevalence of wasting (WHZ < -2 Z scores ) in children
< 5 y
17 % (BDHS, 2007) 10%
↓ in XN among pregnant women, lactating women and
children aged 12 -59 mo)
2.4 %; 2.7%, 0.04 % (IPHN/UNICEF/HKI, 2005)
< 1%
↓ in the prevalence of anemia in < 5 y child, adolescents and
in pregnant women
Children < 5 -48% Adolescent girls 30% Pregnant women 46%
(National Anemia survey 2001 -3)
23%
↓ in prevalence of I deficiency (UIE < 100 mcg/L of school age
6-12 y children)
34.6% (IDD survey 2005) 23%
↑ in rate of EBF in infants under < 6 mo
43% (BDHS, 2007) 50%
↑ in the rate of 6-24 mo children fed minimum
acceptable diet
42% (BDHS, 2007) 52%
NUTRITION OPERATIONAL PLAN INDICATORS
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Indicators Unit measurements
Base line (with yr and data
source)
Projected target Mid 2014 Mid 2016
(1) (2) (3) (4) (5)Prevalence of XN
among < 5 y % children 0.04% NSP 2006 <1% < 1%
% of children 6-59 mo receiving VA
% children 88.3% BDHS 2007 90% > 90%
% of VA supplementation in post partum women
% PP women 19.5% BDHS 2007 50% > 90%
Rate of EBF in infants under < 6
mo
% children 43% BDHS 2007 47% 50%
% children 6-23 mo fed minimum
acceptable diet
% children 41.5% BDHS 2007 48% 52%
Prevalence of anemia among
pregnant women
% pregnant women 46% National Survey 2001
40% 35%
Prevalence of anemia among
children 6-59 mo
% of children 48% National Survey 2001
40% 35%
Prevalence of iodine deficiency
% of school age children
34.6% IDD survey 2005
30% 23%
# of MOs trained in nutrition services
delivery
No of MO in UHC 0 578 (60%) 964 (100%)
# CC workers trained in nutrition services delivery
No of HA, FWA and CHP
0 27,000 (60%) 40,500 (100%)
% of UHCs having a functional nutrition corner established
# of Upazila Health Complexes
21 120 (60%) 200 (100 %)
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Unhealthy diets, physical inactivity and smoking are confirmed risk behaviours for chronic diseases
Biological risk factors of HT, obesity and lipidemia are firmly established as risk factors for CHD, stroke and diabetes
Nutrients and physical activity influence gene expression and may define susceptibility
Major biological and behavioral risk factors emerge and act in early life and continue to have a negative impact throughout the life course
Major biological factors can continue to affect the health of the next generation
Intervening throughout life : Application of a life course approach to the prevention and control of CD
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Globally, trends in the prevalence of many risk factors are upwards especially for obesity, physical inactivity and in the developing world particularly, smoking
Selected interventions are effective but must extend beyond individual risk factors and continue throughout the life course
Some preventative interventions early in life offer life-long benefits
Improving diets and increasing levels and increasing levels of physical activity and older people will reduce chronic disease risks for death and disability
Secondary prevention through diet and physical activity is a complementary strategy in retarding the progression of existing chronic diseases and decreasing mortality and the disease burden from such diseases
Intervening throughout life : Application of a life course approach to the prevention and control of CD
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- Infant and young child nutrition and treatment of severe undernutrition- Micronutrient supplementation & fortification - Hygiene practices
INSTITUTIONS
POLITICAL & IDEOLOGICAL FRAMEWORK
ECONOMIC STRUCTURE
RESOURCESENVIRONMENT, TECHNOLOGY, PEOPLE
Food/nutrientintake
Health
Water/Sanitation
Health services
Interventions
Immediate causes
Underlying causes
Basic causes
SHORT
ROUTES
LONG
ROUTES
- Agriculture & food security- Health Systems - Soc. Protection/safety nets- Water & sanitation- Gender & Development- Girls’ Education-Climate change
Maternal and child-
care practices
Access to food
Determinants of Child Nutrition and Interventions to Address them
Adapted from UNICEF 1990
- Poverty reduction & economic growth programs-Governance, stewardship capacities & management-Trade & patents (&role of private sector)- Conflict Resolution- Environmental Safeguards
Nutrition specific interventions
Nutrition sensitive interventions
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THANK YOU FOR YOUR KIND
ATTENTION !