In Mexico, malnutrition continues to be an important public health problem in children under 5 years of age

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1 Impact of the poverty alleviation program Oportunidades on diverse indicators of nutritional status in Mexican small children Presented by: Salvador Villalpando, M.D., PhD Centro de Investigación en Nutrición y Salud Instituto Nacional de Salud Pública Cuernavaca, México INSTITUTO NACIONAL DE SALUD PUBLICA In Mexico, malnutrition continues to be an important public health problem in children under 5 years of age Stunting Socio-economic status (deciles) Anemia Source: National Nutrition Survey

2 The organized social response Oportunidades Fortified food Fortified milk LICONSA Wheat and corn flour fortification Program for Indian population < 2 years School age 5-12 years Oportunidades: fortified drink for pregnant and lactating women Adults Oportunidades has a high potential to impact on the nutritional status of children Targeted to vulnerable communities and families (regional and socio-economic criteria) Targeting within the household to vulnerable groups Pregnant and lactating women Children under 2 yr of age Benefit package addresses principal direct causes of malnutrition 2

3 Oportunidades is a conditional cash transfer program for families living in extreme poverty Benefits Co-responsabilities of beneficiary families Educational scholarships Cash transfer Fortified food supplements Regular assistance of child in school Assistance of family members to preventative health care Health and nutrition education Growth of the Oportunidades program Beneficiary families Communities Municipalities States Annual budget (in millions of US $) Schools with children receiving scholarships Children receiving scholarships , $ 3 9, , 2, $3, 12, 5 2 3

4 Oportunidades evaluation activities (IFPRI) Rural evaluation (Randomized) ENCASEH IFPRI - CIESAS -CIESAS Basal I panel II y III panel IV y V panel VI panel Additional small scale studies on diverse topics implemented over entire period CIDE- CIESAS Evaluation SEMI- URBAN Basal I panel Urban evaluation (matched) II panel Household expenditure of families in Oportunidades compared to matched controls (IFPRI report) Overall expenditure 14% Expenditure in food 11% Caloric intake increased by 7% More purchases of fruits, vegetables and animal products. Skoufias E et al., IFPRI 1999; Hoddinottet al IFPRI 2 Little changes in the habitual intake of children under 5 years of age. Rivera et al., Report Sedesol, 24 4

5 Characteristics of the fortified food supplement Nutrisano (pap) for children Milk based Fortified with multiple micronutrients All children 4 to 23 mo of age Children 2 to 4 yr of age with low weight for age Nutrisano (44 g dry mass) Energy, kcal 194 Protein, g 5.8 Total Fat, g 6.6 CHO, g 27.9 Sodium, mg 24.5 Iron, mg 1. Zinc, mg 1. Vit A, μg 4 Vit E, mg 6. Vit C, mg 5. Vit B 12, μg.7 Folic Acid, μg 5. Riboflavin, mg.8 Nutrisano is well accepted and consumed by a large proportion of beneficaries Rural and Urban Mexico (results of 4 surveys over one yr period): Consumed regularly (4+ x/wk) 33% 5% Consumed irregularly (1-3 x/wk) 17% Not consumed because finished or 43% did not receive Not consumed because did not go to pick up 1% Not consumed because child does not/reaction 3% 7% Not consumed for other, diverse reasons 3% Consistent results: Over one yr period Surveys in rural and urban Mexico 5

6 Energy intake in children by status of incorporation in Oportunidades and consumption of Nutrisano Dieta habitual Nutrisano Consumo de energía (kcal) meses meses meses meses Sin Con Con Sin Con Con Sin Con Con Sin Con Con C NC C NC C NC C NC Estatus de incorporación a Oportunidades y consumo de Nutrisano Zinc intake in children by status of incorporation in Oportunidades and consumption of Nutrisano Consumo de zinc (mg) Dieta habitual Nutrisano 6-12 meses meses meses meses Sin Con Con Sin Con Con Sin Con Con Sin Con Con C NC C NC C NC C NC Estatus de incorporación a Oportunidades y consumo de Nutrisano 6

7 Impact of Oportunidades on the prevalence of anemia in rural Mexico after 1 year of implementation (1999) P R E V A L% E N C E ** * Adjusted by age, using a GEE model ** p < Matched controls Oportunidades Source: Rivera et al., JAMA 24 The modest results in anemia were attributted to the low bioavailability of reduced iron used as fortificant An iron bioavailability study proved right Fe-58 absorption (%) Sulfate Fumarate Reduced iron + Na2EDTA Perez E and Villalpando S, J Nutr 25 7

8 The pap was reformulated and efficacy tested in 24 Basal Final Ferritin ng/dl Dif=6. * Dif=5.6 * Dif= Gluconate Sulfate Control *p<.4 Villalpando et al JPGN, 28 Impact on the prevalence of anemia in beneficiary children of Oportunidades in the National Nutrition Survey 26 and matched controls from NNS Matched controls ENN-99 Oportunidades PP PP pp Prevalence (%) Age (years) 8

9 Impact of Oportunidades on height* after 2 yrs in children from the poorest families, less than 6 mo of age at baseline Increment in height (cm) ** Exposed 1 year ** Poorest Exposed 2 years Less poor * Adjusted by age and length in 1998, using a random-intercept linear model. ** P <.5 Rivera et al, JAMA, 24 Oportunidades had a positive impact on child linear growth in urban areas Difference in height, Oportunidades-control in 24 (cm) n = 437 p<.5 n = 26 p<.5 n = 96 p=.5 <24 <12 <6 Child age in 22 (mo) Paired on: propensity score, age, height in 22, sex and maternal height Source: Neufeld et al, In preparation 9

10 Impact on the prevalence of stunting in beneficiary children of Oportunidades in the National Nutrition Survey 26 and matched controls from NNS Matched Control ENN-99 Oportunidades 26 Prevalence (%) * = p < * 8.7 PP 6.7 PP 26.8 younger than 5 years Conclusions 1. Oportunidades has had an important impact on child growth and anemia The overall difference in the prevalence of anemia between the two National Nutrition Surveys yield 86, children <5 years spared from anemia in 6 years. Oportunidades contributed with 28% (243,127 children) to such a reduction. Other interventions as the fortified milk program Liconsa (27%, 233,6 children) also contributed substantially. Stunting and anemia continue to be important problems in the Oportunidades population Reformulating the pap improved efficacy to further reduce anemia 1

11 Conclusions 2. Despite its acceptability, consumption of the fortified food supplements by the target population is considerably less than desirable Program may not be able to deter intra-family sharing But improve delivery system Recommendations 1. The Oportunidades program and specifically, the health education component of the program is a under-utilized resource to promote healthy dietary habits in the family Child feeding including breast-feeding, complementary feeding and the appropriate use of food supplements Specific recommendations for food purchases using monetary transfers, e.g. fruits and vegetables Promotion of healthy weight, e.g. weight monitoring in adults 11

12 Statistical methods for comparisons between National Surveys Randomly selected subsample of beneficiaries of Oportunidades in the 26 Survey Matched control (nnmatch in Stata) from the 1999 Survey: Same municipalities Probability of incorporating in program based on observable demographic and socio-economic characteristics (propensity score) Factors known to influence outcome: age and sex 12