BEST Practices Intervention based on The Lancet s Series on Maternal and Child Undernutrition 2008 dan 2013 Abdul Razak Thaha Institut Gizi Indonesia Fakultas Kesehatan Masyarakat Universitas Hasanuddin KPIG, Temu Ilmiah Internasional dan Kongres Nasional PERSAGI XX The Sahid Jogja Hotel, Yogyakarta 25-30 November 2014
IUGR, Stunting and Severe Wasting Together were responsible for more than one-third about 35% of child deaths and 11% of the global total disease burden More than 3.6 million mothers and children die each year as a result of undernutrition The very high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of proven interventions
Long-Term Effects of Early Undernutrition There is relationships between indices of maternal and child undernutrition (maternal height, birthweight, IUGR, and weight, height, and bodymass index at 2 years) and adult outcomes (height, schooling, income, offspring bodyweight, bodymass index, glucose concentrations, blood pressure) In the low-and middle-income countries, these relationships related to blood lipids, cardiovascular disease, lung and immune function, cancers, osteoporosis and mental illness
Stunting Increases Chronic Disease Risk as Adults Stunting in the first 2 years leads to irreversible damage into adult life Young children who are undernourished and gain weight rapidly laterare at high risk of nutrition-related chronic diseases No evidence that rapid weight or length gain in first 2 years of lifeincreases the risk of chronic disease The prevention of maternal and child undernutrition is a long-terminvestment that will benefit the current generation and their children
Evidence-Based Interventions Systematic review of efficacy or effectiveness of 45 possible interventions that affect maternal and child undernutrition and nutritionrelated outcomes, including: 1. Breastfeeding promotion 2. Complementary feeding promotion 3. strategies with or without provision of food supplements 4. Micronutrient interventions (fortification & ) 5. General supportive strategies for improving family and community nutrition and disease burden reduction 6. Interventions for the treatment of severe acute malnutrition
Interventions with Sufficient Evidence to Implement in All Countries Maternal and Birth Outcomes Iron folate Maternal supplements of multiple micronutrients Maternal iodine through iodization of salt Maternal calcium Interventions to reduce tobacco consumption or indoor air pollution Newborn Babies Promotion of breastfeeding (individual and group counseling) Infants and Children Promotion of breastfeeding (individual And group counseling) Behavior change communication for improved complementary feeding Zinc Zinc in management of diarrhe Vitamin A fortification or Universal salt iodization Handwashing or hygiene interventions Treatment of SAM
Interventions with Sufficient Evidence to Implement in Specific Situational Contexts Maternal and Birth Outcomes Maternal supplements of balanced energy and protein Maternal iodine supplements Maternal deworming in pregnancy Intermittent preventative treatment for malaria Insecticide-treated bednets Newborn Babies Neonatal vitamin A Delayed cord clamping Infants and Children Conditional cash transfer programs (with nutritional education) Deworming Iron fortification and programs Insecticide-treated bednets
Evidence-Based Interventions Interventions showing the most promise for reducing child deaths and future disease burden include: Breastfeeding promotion Appropriate complementary feeding Supplementation with vitamin A and zinc Appropriate management of severe acute malnutrition Conception through 24 months is the critical window of opportunity to prevent and intervene to reduce stunting
Key Challenges at National Level 1 2 3 4 5 6 7 Not Doing the Wrong Things Getting Nutrition on the National Agenda Doing the Right Things Using Data for Nutrition Decision Making Building Strategic and Operational Capacity Using Data for Nutrition Decision Making Building Strategic and Operational Capacity
Social, Economy and Politics Support National nutrition programs should effectively monitor and evaluate target populations that benefit most from interventions pregnant women and children under 2 Countries should focus resources on interventions with proven effectiveness and implement them at scale as quickly as possible Economic and social policies addressing poverty, trade and agriculture associated with rapid improvements in nutritional status should also be implemented Governments should look to incorporate nutrition goals into programs that may not directly address health, but that could benefit from improved national nutrition Nutrition is a central component for human, social and economic development
Nutrition Interventions Reviewed Lancet 2013 Women of reprod age and pregnancy Neonates Infants and young children Disease prevention and management Folic acid suppl. Iron and iron-folate suppl. MMN suppl. Calcium suppl. Iodine through iodisation of salt Maternal with balanced energy Protein Delayed cord clamping Neonatal vitamin K administration Vitamin A Kangaroo mother care and promotion of breastfeeding IYCF promotion Preventive vitamin A suppl ( 6-59 months) Iron suppl. MMN suppl. Zinc suppl. Management of MAM Management of SAM WASH interventions Maternal drowning Deworming in children Feeding practices in diarrhoea Zinc therapy for diarrhoea IPTp/ITN for malaria in pregnancy Malaria prophylaxis in Children 2013 11
Nutrition-sensitive Interventions and Programmes Lancet 2013 Interventions or programmes that address the underlying determinants of fetal and child nutrition and development (food, care, health) and incorporate specific nutrition goals and actions. Nutrition-sensitive programmes can serve as delivery platforms for nutrition-specific interventions, potentially increasing their scale, coverage and effectiveness. Agriculture and food security Early child development Women s empowerment Schooling Health & family planning services Social safety nets Maternal mental health Child protection Water, sanitation & hygiene
Benefits during the life course Morbidity and Mortality in Childhood Cognitive, motor, socioemotional development School performance and learning capacity Adult Status Obesity and NCDs Work capacity and productivity Nutrition specific interventions and programmes Adolescent health and preconception nutrition Maternal dietary Micronutrient or fortification Breastfeeding and complementary feeding Dietary diversification Feeding behaviors and stimulation Treatment of serves acute malnutrition Disease prevention and management Nutrition interventions in emergencies Optimum fetal and child nutrition and development Breastfeeding nutrient rich foods and eating routine Food security, including availability, economic access, and use of food Feeding and caregiving practice, parenting, stimulation Feeding and caregiving resources (maternal, household, and community levels) Low burden of infectious diseases Access to and use of health services, a safe and hygienic environment Knowledge and evidence Politics and government Leadership, capacity and financial resources Social, economic, and environmental context (national and global) Black.RE et al, The 2013 Lancet Series on Maternal and Child Nutrition Nutrition sensitive programmes and approaches Agriculture and Food Security Social safety nets Early child development Maternal mental health Women s empowerment Child protection Classroom education Water and sanitation Health ans family planning services Building an enabling environment Rigorous evaluation Advocacy strategies Horizontal and vertical coordination Accountability incentives regulation, legislation Leadership programmes Capacity investments Domestic resource mobilitation
Building an enabling environment Rigorous evaluation Advocacy strategies Horizontal and vertical coordination Accountability incentives regulation, legislation Leadership programmes Capacity investments Domestic resource mobilitation Knowledge and evidence Politics and government Leadership, capacity and financial resources Social, economic, and environmental context (national and global)
Nutrition sensitive programmes and Agriculture and Food Security Social safety nets Early child development Maternal mental health Women s empowerment Child protection Classroom education Water and sanitation Health ans family planning services approaches Food security, including availability, economic access, and use of food Feeding and caregiving resources (maternal, household, and community levels Access to and use of health services, a safe and hygienic environment
Nutrition specific interventions and programmes Adolescent health and preconception nutrition Maternal dietary Micronutrient or fortification Breastfeeding and complementary feeding Dietary diversification Feeding behaviors and stimulation Treatment of serves acute malnutrition Disease prevention and management Nutrition interventions in emergencies Breastfeeding, nutrient rich foods and eating routine Feeding and caregiving practice, parenting, stimulation Low burden of infectious diseases
TUJUAN PEMBELAJARAN OPTIMUM FETAL AND CHILD NUTRITION AND DEVELOPMENT
Benefits during the life course MORBIDITY & MORTALITY MATERNAL AND CHILDHOOD COGNITIVE, MOTOR, SOCIOEMOTIONAL DEVELOPMENT SCHOOL PERFORMANCE & LEARNING CAPACITY ADULT STATURE OBESITY & NCDs WORK CAPACITY & PRODUCTIVITY
Preconception care family planning,delayed age of first pregnancy, prolonging of inter-pregnancy interval, abortion care, psychosocial care Folic acid Multiple micronutrient Calcium Balanced energy protein Iron or Iron plus folate Iodine Tobacco cessation Delayed card damping Early initiation of breast feeding Vitamin K administration Neonatal Vitamin A Kangaroo mother care Exclusive breast feeding Complementary feeding Vitamin A (6-59 months) Preventive zinc Multiple micronutrient Iron Decreased maternal and childhood morbidity and mortality Improved cognition growth and neurodevelopment al outcomes Adolescent WRA and Pregnancy Neonates Infants and Children Disease prevention and treatment Disease prevention and treatment Malaria prevention in women Maternal deworming Obesity prevention Management of SAM Management of MAM Therapeutic zinc for diarrhea WASH Feeding in diarrhea Malaria prevention in children Deworming in children Obesity prevention Delivery platform, Community delivery platforms, integrated management of childhood illnesses, child health days, school based delivery platforms, financial flatforms, fortification strategies, nutrition in emergency Increased work capacity and productivity Economic developmen Bold-interventions modelled Italic-Other intervention reviewed WRA-women of reprductive age. WASH-water, sanitation, and hygiene. SAM-severe acute malnutrition. MAM-moderate AM.
Adolescent Preconception care family planning, delayed age of first pregnancy, prolonging of inter-pregnancy interval, abortion care, psychosocial care
WRA and Pregnancy Folic acid Multiple micronutrient Calcium Balanced energy protein Iron or Iron plus folate Iodine Tobacco cessation Disease Preventon and Treatment Malaria prevention in women Maternal deworming Obesity prevention
Neonatus Delayed card damping Early initiation of breast feeding Vitamin K administration Neonatal Vitamin A Kangaroo mother care
Infants and Children Exclusive breast feeding Complementary feeding Vitamin A (6-59 months) Preventive zinc Multiple micronutrient Iron Disease Prevention and Treatment: Management of SAM Management of MAM Therapeutic zinc for diarrhea WASH Feeding in diarrhea Malaria prevention in children Deworming in children Obesity prevention
Delivery platform Community delivery platforms, integrated management of childhood illnesses, child health days, school based delivery platforms, financial platforms, fortification strategies, nutrition in emergency
2008 Series Identified need to focus on first 1000 days of life Called for greater attention to national nutrition programmes, integration with health programmes and inter-sectoral approaches. Specific and Sensitive Intervention 2013 Series Re-evaluated problems of maternal and child undernutrition Considered growing problem of overweight and obesity Assessed the current and needed national and global response since 2008
Shifts in the Nutrition Landscape 26
The Benefit of the First 1000 Days of Life The building blocks of adult health and productivity begin before conception and take shape very early in life. The notion of the first 1000 days (conception through to 24 months of age) has attracted attention as the blueprint for lifespan trajectories. When threats such as undernutrition and environmental stress occur, lifespan trajectories can be disrupted, resulting in poor school performance, reduced economic opportunities, and chronic health problems. As these conditions extend into the reproductive years and adulthood, they afect subsequent generations, perpetuating a negative cycle of economic and health disparities. The first 1000 days provide sensitive opportunities for interventions that can prevent early threats and protect children from lifelong negative consequenses -Lancet, Vol. 384, October 4, 2014-27
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