Early Nutrition and Adult Noncommunicable diseases: A vital link that must be broken Commonwealth Health Ministers Meeting WHO, Geneva May 14, 2011 Anna Lartey (Associate Professor) Department of Nutrition & Food Science University of Ghana 1
Global status report on non-communicable disease (WHO, April 2010) NCD deaths are projected to increase by 15% globally between 2010 and 2020. The greatest increases will be in Africa, the Eastern Mediterranean, and South-East Asia, where they will increase by over 20% 2
Total deaths by broad cause group by WHO Region and by sex Source: Global status report on non-communicable disease (WHO, April 2010) 3
Age standardized prevalence of diabetes by WHO Region and by sex Source: Global status report on non-communicable disease (WHO, April 2010) 4
Age standardized prevalence of Hypertension in adults ages 25+ years by WHO Region and by sex Source: Global status report on non-communicable disease (WHO, April 2010) 5
Age standardized prevalence of overweight in adults ages 20+ years by WHO Region and by sex Source: Global status report on non-communicable disease (WHO, April 2010) 6
Nutrition Transition 7
Early Nutritional influences on NCDs (Developmental Origins of Adult Health and Disease (DOHAD) Maternal nutrition, fetal nutrition and disease in later life (Barker D;1992) In the last 15 years new information suggest the nutritional influences encountered earlier in life may be of equal importance in determining CVD risk 8
Adverse environmental conditions Fetus Dies Adaptation to survive Metabolic/Nutritional Programming 9
Metabolic Programming Fetal under-nutrition Brain sparing Down regulation of growth Altered Body composition Impaired development: Blood vessels, liver, kidney and pancreas Hyperlipidemia Hypertension Reduced insulin secretion and sensitivity Central Obesity Reduced Muscle Insulin Resistance Type 2 Diabetes and CHD in Adult life Source: C. Fall 2009 10
Evidence in support of Developmental origins of disease from animal studies In rats, maternal diet (protein) restriction in pregnancy High blood pressure Impaired glucose tolerance Insulin resistance Altered hepatic function in the adult offspring (Woodall et al 1996; Langley et al 1994; Pickard et al 1996) 11
Evidence in support of Developmental origins of disease from Humans Indian children: study examined that association between LBW and CVD risk factors (Bavdekar, et al 2000) At 4 years: LBW was associated with higher plasma conc glucose after an oral glucose load At 8 years: LBW children had high LDL cholesterol, higher systolic pressure and insulin resistance 12
Low Birth Weight and Stunting are Related 70 The prevalence of Low Birth Weight and Stunting Prevalence of stunting (%) 60 50 40 30 20 10 Regions South America Middle America / Caribbean South East Asia South Asia Near East / North Africa Sub-Saharan Africa China 0 0 10 20 30 40 50 60 Prevalence of Low Birth Weight (%) Extracted from: ACC/SCN, 1997 Source of slide: R Uauy 13
Maternal Underweight & LBW are Related Source of slide: R Uauy UN/SCN 6 th WNR 2010 14
Proportion of babies born low birth weight by region 30 25 Percentage 20 15 10 5 0 SSA MENA S. ASIA L. America All developing Countries Regions SSA= Sub Saharan Africa; MENA= Middle East and North Africa Source of data: UNICEF State of the World s Children, 2009 15
Implications of Developmental origins of adult disease for Developing countries Identification of critical periods during which conditions can be programmed (-9 to 24mo) raises concern about the potential for huge increase in the prevalence of NCDs in low income countries, especially countries going through the nutrition transition. Good news: We have knowledge on what to do to avoid disease programming in utero and during early infancy. 16
Window of opportunity to break link on nutrition programming (-9 to 24 mo) 17
Early nutrition matters Improve maternal nutrition before and during pregnancy (diet is nutrient dense, adequate micronutrients). Adequate maternal diet is important to break the intergenerational effect of low birth weight 18
Early nutrition matters Promote Exclusive Breastfeeding 19
Risk of Overweight in Adolescence by Duration of Breastfeeding in Infancy 1.4 Protective effect of breastfeeding on obesity 1.2 Odds Ratio (95% CI) 1.0 0.8 0.6 0.4 1 1-3 4-6 7-9 >9 Duration of Breastfeeding (mo) Source: Gillman et al., 2001
Early nutrition matters: Promote adequate complementary feeding 45 <6 mo 6-<12 mo 12-36 mo >36 mo 40 % of children under 5 y stunted 35 30 25 20 15 10 5 0 Kenya Ghana Zimbabwe Morocco Stunting prevalence by age categories (Source of data: Country DHS data) 21
90% of All Stunted Children Live in Just 36 Countries PAPER 1
Consequences of stunting Short term Increased infant morbidity Increased perinatal mortality Increased risk of maternal mortality Delayed motor development Adverse cognitive development Long term Reduced adult stature Lower educational attainment Lower adult productivity and income earnings Increased risk of obesity Processes leading to stunting (poor maternal diet) are associated with insulin resistance, diabetes and CVD in offspring later in life Inter-generational effects of stunting in girls 23
Early nutrition matters: Promote adequate complementary feeding *Improve the nutritional quality of complementary foods (feeding a variety of foods to improve dietary diversity). *Micronutrient fortified complementary foods may be needed where local complementary food quality is poor. 24
Thirteen evidence-based interventions that when scaled up will make a difference (Lancet series 2008) Promotion of Breastfeeding Complementary feeding Improved hygienic practices Vitamin A supplementation Zinc supplements for diarrhea management Multiple micronutrient powders De-worming Iron-folic acid supplements for pregnant women Iodized oil capsules Salt iodization Iron fortification of staple foods Prevention and treatment of moderate undernutrition with special foods Treatment of severe undernutrition with ready-touse therapeutic foods (RUTF) 25
What will it cost to scale up these 13 interventions in high malnutrition burden countries? Annually: 10.3 billion USD Benefit: Prevent annually 1.1 million deaths, 30 million cases of stunting, Avert the loss of 30 million disability adjusted life years ; Substantial economic gains 26
Scaling Up Nutrition movement SUN: Scaling Up Nutrition Documents 27
Scaling Up Nutrition movement Scaling Up Nutrition (SUN) is a framework that lays out a new approach to improving nutrition for mothers and children during the window of opportunity from pregnancy to age two. SUN focuses on 13 key direct nutrition interventions. SUN is led by a cross-sector, multi-partner Transition Team, chaired by Dr. David Nabarro, Special Representative of the UN Secretary General for Food Security and Nutrition 28
Scaling Up Nutrition movement SUN works with donors, development agencies, civil society and others within countries and at an international level, to align programs and investments with national plans. 29
Scaling Up Nutrition movement Early Riser countries: These are early adopters of the SUN framework. These countries have committed to establishing national nutrition priorities and developing plans that align with the SUN approach of scaling up Nutrition Countries must apply with a formal letter of request from a high-ranking government official (e.g. Head of Government or Minister of health) to David Nabarro: david.nabarro@undp.org 30
Scaling Up Nutrition movement Early Riser countries: Ethiopia, Guatemala, Ghana, Laos, Malawi, Mali, Niger, Peru, Uganda, Zambia Others: Bangladesh, Nepal, Senegal, Tanzania 31
Take Home Messages: Early nutrition matters when addressing NCDs Take advantage of the window of opportunity (-9-24 mo) to break the link As Ministers of Health: take advantage of the SUN activities and make nutrition a priority 32