Nutrition Through the Lifecycle
Maternal Nutrition
Low Birth weight
Why focus on women’s nutrition?• First and foremost because women have a
basic right to food security and good health
• However, due to their multiple roles of reproducing, nurturing, caring and producing, the social, economic, health and development implications of women’s malnutrition can be devastating
Why focus on women’s nutrition?...• Consequences include
Infections
Obstructed labor
Low birth weight
Neonatal and infant mortality
Maternal mortality
Undernourished mothers are less productive and this
has economical implications as well as implications for
household food security
What is and why the lifecycle approach?
The Typical Scenario in AfricaA woman enters pregnancy undernourished, anemic and
probably deficient in other micronutrients →
She gives birth to an infant with LBW who immediately starts life at a disadvantage → → childhood and adolescence → →
The female adolescent enters womanhood & pregnancy malnourished….and the cycle continues!
The Lifecycle approach…why?• Focusing on female nutrition throughout the
lifecycle – from infancy through childhood to adolescence and the reproductive years may give greater dividends in terms of improved nutritional status of both mother and child
The Lifecycle approach…why?...• The benefits spill over to the elderly who
because of nutritional investments throughout the lifecycle are healthier in later years
• Elderly are a major resource for the care of infants and young children
• Healthier elders could translate into improved quality of care for infants and young children while reducing the burden of women in caring for sick elders
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• Maternal Nutrition
• Major Issues
Maternal Malnutrition:A Life-Cycle Issue
· Infancy and early childhood (0-24 months)– Suboptimal breastfeeding practices– Inadequate complementary foods – Infrequent feeding – Frequent infections
· Childhood (2-9 years) – Poor diets – Poor health care– Poor education
Maternal Malnutrition:A Life-Cycle Issue…
· Adolescence (10-19 years)– Increased nutritional demands– Greater iron needs – Early pregnancies
· Pregnancy and lactation – Higher nutritional requirements– Increased micronutrient needs – Closely-spaced reproductive cycles
Maternal Malnutrition:A Life-Cycle Issue…
· Throughout life– Food insecurity– Inadequate diets – Recurrent infections– Frequent parasites– Poor health care– Heavy workloads– Gender inequities
The IntergenerationalCycle of Malnutrition
Child growth failure
Early pregnancy
Small adult women
Low birth weight babies
Low weight and height in teens
ACC/SCN, 1992
Maternal Malnutrition…
• Women who were malnourished as infants are more likely to give birth to malnourished babies
• Infant malnutrition, especially for girls, effectively perpetuates poverty, hunger, and malnutrition across generations
Maternal Nutrition and the MDGs• Improved maternal nutrition is essential for
attaining many of the MDG targets:
– Reducing maternal mortality by three quarters between 1990 and 2015
– Reducing hunger and malnutrition (Goal 1)
– Achieving universal education (Goal 2)
– Promoting gender equality and women’s empowerment (Goal 3)
Mechanism for poverty transmissionthroughout the life course
Poverty is biologically transmitted across generations through malnutrition
– Maternal underweight• Key risk factor in low birth weight
– Low birth weight• Risk factor for child stunting and underweight
Maternal undernutrition
–Chronic energy deficiency
–Micronutrient deficiencies
Chronic energy deficiency• Maternal body-mass-index (BMI)
= Weight (in kg)/height (in m) squared,
• Measure of chronic energy deficiency (CED)– Severe CED : BMI<16
– Mild/moderate CED : BMI 16 - 18.49
– No CED : BMI 18.5 - 24.99
– Overweight : BMI 25 - 29.99
– Obese: BMI >=30
Major Interventionsin Maternal Nutrition
· Improve weight and height
· Improve micronutrient status
Improving Maternal Weight
· Increase caloric intake
· Reduce energy expenditure
· Reduce caloric depletion
Improving Maternal Height
· Weight increases can be achieved within a
woman’s reproductive life’
May not be true for height
· Increase birth weight
· Enhance infant growth
· Improve adolescent growth
Optimal Behaviorsto Improve Women’s Nutrition
Early Infancy: Exclusive breastfeeding to about six months of age
Optimal Behaviorsto Improve Women’s Nutrition…
• Late Infancy and Childhood: – Appropriate
complementary feeding from about six months
Optimal Behaviorsto Improve Women’s Nutrition…
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• Late Infancy and Childhood:
Continue frequent on-demand breastfeeding to 24 months and beyond
Optimal Behaviorsto Improve Women’s Nutrition…
Pregnancy:• Increase food intake• Take iron+folic acid supplements daily• Reduce workload
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Optimal Behaviorsto Improve Women’s Nutrition
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Lactation:• Increase food intake• Take a high dose
vitamin A at delivery• Reduce workload
Vitamin A PostpartumSupplementation
• Recommendations
Current (WHO):
200,000 IU in 1 dose, as soon as possible after delivery
Proposed:
400,000 IU in 2 doses of 200,000 IU at least 1 day apart, as soon as possible after delivery
Optimal Behaviorsto Improve Women’s Nutrition
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• Delay first pregnancy
• Increase birth intervals
Optimal Behaviorsto Improve Women’s Nutrition
At all times:• Increase food intake if underweight• Diversify the diet• Use iodized salt• Control parasites• Take micronutrient supplements if needed
Improving Women’s Micronutrient Status
· Dietary modification
· Parasite control
· Fortification
· Supplementation
Dietary Modification to Improve Women’s Micronutrient Status
Increase:
· Micronutrient intake
· Bioavailability of micronutrient intake
Parasite Control to Improve Women’s Micronutrient Status
Reduce parasite transmission:
Improve hygiene
Increase access to treatments
Fortification to Improve Women’s Micronutrient Status
Medium-term strategy:· Improves micronutrient intake· Without changing food habits
Requires:· Appropriate nutrient fortificant· Appropriate food vehicle
Examples of Micronutrient Food Fortification
Vitamin A in sugar
Iron in wheat flour
Iodine in salt
Multiple fortification iron + iodine in salt iron + vit B in wheat flour
Supplementation to Improve Women’s Micronutrient Status
Preventive or therapeutic
Daily or periodic
Targeted to groups
Mass distribution
Iron+Folic Acid Supplementationfor Women of Reproductive Age
Prior to and between pregnancies:
Periodic supplementation (60 mg of iron and
400 μg folic acid) daily for 3 months for: ● Girls before puberty and during adolescence● Women of childbearing age
Elements of a Successful Supplementation Program
· Supplement supply· Delivery system· Women’s demand and compliance· Monitoring and evaluation
Supplement Supply
· Data-based ordering
· Timely procurement process
· Timely distribution to delivery points
Supplement Delivery System
· Accessible to target population
· Appropriate Staff:- Motivated- Approachable- Supportive- Adequately trained
Women’s Demand and Compliance
· Communications component- Community awareness
- Information on side effects
· Good quality supplements
Monitoring and Evaluation
· Monitor at all levels:- Supply- Coverage- Compliance- Communications component
· Evaluate impact on prevalence
Low Birth Weight (LBW)
Low Birth Weight….• Birthweight is the first weight of the foetus
or newborn obtained after birth.
• For live births, birthweight should preferably be measured within the first hour of life, before significant postnatal weight loss has occurred.
LBW - Incidence
• The incidence of low birthweight in a population is the percentage of live births that weigh less than 2,500 g out of the total of live births during the same time period.
LBW - Measurement• Data Sources:
– Developed countries - service-based data and national birth registration systems
– Developing countries - national household surveys, as well as data from routine reporting systems
• Since about 1990 from mothers participating in nationally representative household surveys, mostly the USAID supported DHS and the UNICEF-supported MICS.
LBW – Measurement…• Births that were weighed were more likely to
involve mothers who were – better educated and resided in urban areas,– in a medical facility and with assistance from skilled
health personnel.
• These characteristics are generally associated with higher birthweights and, therefore, the resulting estimates were still likely to underestimate the level of low birthweight.
Low birth weight (LBW) – Definition and Magnitude
• Birth weight below 2500 grams (5.5 pounds),– 30% in South Asia,
– 14% in sub-Saharan Africa,
– 15% in Middle East and North Africa,
– 10% in Latin America,
• Very low birth weight : <1,500 grams
LBW - Significance
• Low birth weight infants:– High risk of neonatal or infant mortality,
– Less likely to catch-up significantly,
– High risk of developmental deficits,
– More likely to be underweight or stunted,
– Consequences extend into adulthood,
• “fetal origins of disease hypothesis”
Causes of LBW
• Intrauterine growth retardation (IUGR)– Intrauterine growth that is less than expected for
length of gestation
– Small for gestational age (SGA)
– More common in Developing countries
• Preterm birth (<37 weeks)– Short duration of pregnancy
– More common in Developed countries
Causes of LBW…
– For the same gestational age, girls weigh less than boys, firstborn infants are lighter than subsequent infants, and twins weigh less than singletons;
– Birthweight is affected to a great extent by the mother’s own foetal growth and her diet from birth to pregnancy, and thus, her body composition at conception;
Causes of LBW…– Poor maternal nutrition during pregnancy
accounts for 14% of IUGR in developing
countries
– Maternal stunting may account for 18.5%
Causes of LBW…
Developing countries;– 50% of all IUGR in rural areas of developing
countries attributable to;
• small maternal size at conception
• low gestational weight gain
Causes of LBW…
Other causes of IUGR, developing
countries;– Malaria in endemic areas
– Maternal infections
– Abnormal placental blood flow or structure
– Foetal infections
Causes of LBW…
Developed countries– Premature delivery
– Cigarette smoking during pregnancy
– Low gestational weight gain
– Low BMI at conception
– Maternal undernutrition - uncommon
– Folic acid deficiency may increase risk of preterm delivery
Classification of LBW/PTD
Gestational age LBW Normal BW
>37 weeks IUGR Normal
<37 weeks Preterm/ Preterm
and/or IUGR
PTD and IUGR asdeterminants of LBW
• Preterm infant may be LBW but have an appropriate weight for its gestational age– LBW only because it was born early
• Preterm infant may also be growth retarded– LBW because of both shortened gestation and
growth retardation
Three types of IUGR
• Group 1:– Born after 37 weeks of gestation and weight less
than 2,500 g at birth
• Group 2:– Newborns are preterm and weigh less than the
10th percentile at birth
• Group 3:– Weigh less than the 10th percentile, but have abirth weight greater than 2,500 g
Types of IUGR
Epidemiology of IUGR
• In 2000, an estimated 11.0% of newborns in developing countries, or 11.7 million infants, have low birth weight at term
• In Asia, 20.9% of newborns are affected, and the sub-region accounts for 80% of all affected newborns worldwide
IUGR…
IUGR affects more newborns than low birth weight;– about 24% or 30 million newborns per year in
developing countries
• Major global human development problem;– profound short- and long-term consequences for
individuals, communities, and whole populations
Consequences of LBW
– Increased risk of morbidity and mortality
– Poor neurodevelopmental outcomes
– Reduced strength and working capacity
– Increased risk of chronic diseases in adulthood
LBW - Prevalence and Trend
Low Birth Weight - Trends (2000-2011)
2000 2005 2011 2000 2005 2011
6
21 21
814
11
28
7 9
6672 70
very small smaller than average Average or larger
Reported birth weight < 2.5 kg
Mothers’ subjective assessment
Only 5% of children in Ethiopia are weighed at birth in 2011
Trends in LBW - LBW on the rise between 1976-1996 in Addis Ababa
70's 80's 90's0
2
4
6
8
10
12
5.8
7.3
11.3Chart Title
Year
Perc
ent L
BW
The odds of LBW in the 90's was 52% higher compared to the 70's
Trends in LBW - Regions
Study area Year of Survey Prevalence
Gondar 196719881996
13.8%11.1%17.8%
Addis Ababa 1997 9.1%
Jimma 20032005
22.5%11.0%
LBW and Malaria
Study area
Sample size Prevalence
Gambella(2003)
Infected Uninfected With placental malaria
Without placental malaria
9 159 44 14
Prevalence of placental malaria: 5%
J. Infect. Dis. 187:1765– 1772.
Factors associated with LBW– Teen age pregnancy (<20 years)
– Shorter stature (<= 150cm)
– Short birth intervals and
– Mothers who come late for antenatal visit and had complications during pregnancy.
– Infections (Malaria…)(Gebremariam A. East Afr Med J. 2005 Nov;82(11):545-6)
• Infant with Low birth weight
• Infancy & childhood up to 5 years - Stunting - Underweight - Wasting
• Women Chronic energy deficiency
Nutritional Status of Children Under Age Five
Vulnerable period
Duration of Breastfeeding by Region
Amhara
Gambela
Tigray
SNNP
Addis Ababa
Affar
Oromiya
Benishangul-Gumuz
Somali
Harari
Dire Dawa
>36>36
26
26
26
25
25
23
22
21
20
How Does Breastfeeding Differ by Country?
Uganda 2000-01
Tanzania 2004-05
Kenya 2003
Eritrea 2002
Mozambique 2003
Malawi 2000
Rwanda 2005
Ethiopia 2005
21
21
22
23
23
24
25
26Chart Title
Exclusive Breastfeeding Under 6 Months
Exclu-sively
breastfed49%
Plus plain water only15%
Plus wa-ter-based
liquids/juice5%
Plus other milk18%
Not breast-feeding
1%
Plus comple-mentary
foods14%
Chart Title
Median Duration of Breastfeeding
Any breast-feeding
Exclusive breastfeeding
Predominant breastfeeding
25.8
2.14.4M
edia
n du
ratio
n in
m
onth
s
Complementary Foods – EDHS 2005
14% of breastfed children under 6 months are already consuming solid or mushy food.
Only 54% of breastfed children age 6-9 months consume solid or mushy food.
Trends in Children’s Nutritional Status (EDHS 2000-2011)
underweight wasting Stunting
47
11
52
38
11
47
29
10
44
EDHS 2000 EDHS2005 EDHS 2011
perc
ent
Evolution of child malnutrition in Ethiopia from 1983-2005 (WMS & DHS)
1983 1992 1996 1997 1998 2000 2005
6064 66 67
5552
4747 47
4347 38
8 8 8 8 9 11 11
Stunting Underweight Wasting
Trends in Child Malnutrition – Urban-Rural difference
1983 1992 1996 1997 1998 2000 20050 0
5855
41 42
30
6064
67 69
5653
48
0 0
3437
3034
23
0 0
48 4844
49
40
0 06
9
8 6 68 8
8
8
911 11
Urban Stunting Rural Stunting Urban Underweight Rural Underweight
Urban Wasting Rural wasting
•Child Malnutrition – Comparison with other African countries
Senegal Egypt Tanzania Kenya* (2003)
Rwanda Ethiopia
16 18
2730
45 47
Prevalence of Stunting, DHS 2005
Egypt Rwanda Tanzania Kenya* (2003)
Senegal Ethiopia
4 45
6
8
11
Prevalence of Wasting, DHS 2005
Egypt Rwanda Tanzania Kenya* (2003)
Senegal Ethiopia
6
1720 20
23
38
Prevalence of Underweight, DHS 2005
key determinants ofGrowth Faltering in Ethiopia
• household resources
• parental education
• food prices and
• maternal nutritional knowledge
• Infant with Low birth weight
• Infancy & childhood up to 5 years
• Women Chronic energy deficiency - BMI & Height
Urban Rural Total
23
3230
19
28 27
20
2927
DHS 2000 DHS 2005 DHS 2011
Percent women BMI <18.5kg/m2, (EDHS 2000-2011)
Percent Women BMI <18.5 (DHS 2000-2005)
TigrayAffar
AmharaOromiya
SomaliB-Gumuz
SNNPGambela
HarariAddis Ababa
Dire Dawa
0 10 20 30 40 50 60
35
42
31
29
48
38
31
39
25
18
27
38
33
27
24
35
33
27
39
21
15
24
DHS 2005 DHS 2000
Ethiopia
Rwanda
Tanzania
Senegal
Kenya
Egypt
27
10
10
12
12
0.5
Percent <18.5 BMI, DHS 2005
Trends in Percentage below 145 cm(EDHS 2000-2011)
Total Urban Rural
4
3
4
3
2
33 3
4
DHS 2000 DHS 2005 DHS 2011
Percentage below 145 cm (EDHS 2000-2005)
Tigray
Affar
Amhara
Oromiya
Somali
B-Gumuz
SNNP
Gambela
Harari
Addis Ababa
Dire Dawa
0 1 2 3 4 5 6 7 8
5
4
4
3
2
3
4
4
2
3
1
3
4
4
2
2
7
4
1
2
2
1
DHS 2005 DHS 2000
•Factors associated with Poor Maternal Nutrition
Birth intervals - EDHS 2000-2011
7-17 18-23 24-35 36-47 48-59 60+
811
38
24
19
1
DHS 2000 DHS 2005 DHS 2011Months since the preceding birth
per
cen
tag
e
Birth intervals < 24 months in 2011 = 20%
25-29 30-34 35-39 40-44 45-49 25-49
20
19 19
18
19 1919 19 19 19 19 1919 19 19 19 19 19
Median age at first birth, EDHS 2000-2011
DHS 2000 DHS 2005 DHS 2011
Current age
Med
ian
ag
e at
fir
st b
irth
•Overweight and Obesity
Emerging Nutrition Problem??
Overweight and Obesity in EDHS 2011
Total Urban Rural
5.7
14.9
2.6
4.7
12.1
2.31
2.8
0.4
Overweight or Obese Overweight Obese
Overweight/obesity trends – EDHS 2005-2011
Overweight or Obese
Overweight Obese
4
3
0.7
6
5
1
2005 2011
Overweight and obesity trends in Urban areas – EDHS 2005-2011
Overweight or Obese Overweight Obese
14
12
2
15
12
3
Urban 2005 Urban 2011
Overweight and obesity trends in Rural areas – EDHS 2005-2011
Overweight or Obese Overweight Obese
2 2
0.3
2.6
2.3
0.4
Rural 2005 Rural 2011
Tigray
Affar
Amhara
Oromiya
Somali
B-Gumuz
SNNP
Gambela
Harari
Addis Ababa
Dire Dawa
2
4
2
5
10
2
3
2
10
18
14
3
4
4
5
16
3
6
7
14
20
19
Regional disparities in levels of Overweight or Obesity, EDHS 2005 - 2011
DHS 2011DHS 2005
Comparison with other countries
Ethiopia
Rwanda
Tanzania
Senegal
Kenya
Egypt
4
12
18
22
23
80
Percent Overweight or Obese, DHS 2005
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