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

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

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

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

MATERNAL, CHILD AND HOUSEHOLD NUTRITION

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

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

Child growth at different ages

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

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

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

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

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.

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

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

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

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)

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

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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 $

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)

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

Dietary guidelines :Healthy food pyramid

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

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

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 %)

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

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

- 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

THANK YOU FOR YOUR KIND

ATTENTION !