Quotes from Nutrition Interventions

- ‘The monograph therefore fills an important gap by providing an overview on which nutrition interventions improve the nutrition status of women and children, with emphasis on the poor in developing countries. The purpose is to define a core menu of proven investment options supported by sound evidence of efficacy. We expect that this review will be a much-consulted reference to support evidence-based nutrition programming in developing countries. This review takes the perspective of low-income Asia, because the study was commissioned by the Asian Development Bank to inform its policy dialogue with Asian governments.’ (iii)

- ‘The review draws on global literature and its findings are relevant to all developing countries. The review emphasizes what works and why – for each of the major nutrition problems in Asia: micronutrient deficiencies (vitamin A, iodine and anemia), low birthweight, maternal malnutrition, child growth retardation and arrested cognitive development in early childhood.’ (iii)

- ‘Asia has a lower prevalence of low birthweight (LBW) than any other continent, ranging from well over 30% in South Central Asia and Bangladesh to less than 10% in the People’s Republic of China, the Philippines, Malaysia, and Thailand. LBW is strongly associated with undernutrition of mothers. About 60% of women in South Asia and 40% in Southeast Asia are underweight (<45 kg). LBW is probably the main reason why over 50% of the children in Asia are underweight. It also increases the risk of other health and developmental problems. Interventions to reduce the prevalence of LBW should therefore receive very high priority. Randomized, controlled, efficacy trials to combat LBW have shown the following. Only supplements that provide more energy, rather than more protein, improve birthweight significantly. In populations where protein intake is inadequate, high protein supplements (>25% of energy) to pregnant women may even increase maternal death rates.’ (v)

- ‘In The Gambia, locally produced biscuits providing 1,017 kcal and 22 g protein per day from mid-pregnancy, reduced LBW prevalence by 39%, increased birthweight by 136 g and reduced infant mortality by about 40%.’ (v)

- ‘Attention should be paid to improving the quality as well as the quantity of food consumed during pregnancy. There is little evidence that supplementation with individual nutrients (including calcium, folic acid, iron, zinc and vitamin A) can improve birthweight, other than possibly through a reduction in preterm delivery. However, micronutrient supplementation of underprivileged pregnant women is extremely important. It can lead to substantial reductions in maternal anemia and may also reduce maternal mortality, birth defects and preterm delivery.’ (v-vi)

- ‘Asia has the highest prevalence of anemia in the world. About half of all anemic women live in the Indian subcontinent.’ (vii)

- ‘No conclusions can be made about the benefits of iron supplementation during pregnancy on maternal or fetal health, function or survival.’ (vii)

- ‘Iron supplementation of anemic preschool children improves their cognitive and physical development.’ (vii)

- ‘Iodine deficiency disorders (IDD) are a serious problem in Asia. Their prevalence in South-East Asia exceeds that in all other regions of the world.’ (viii)

- ‘Cretinism results from maternal iodine deficiency during pregnancy. It can be prevented by supplementing the mother during pregnancy, preferably during the first trimester and no later than the second trimester. Supplementation in late pregnancy, if that is the first time the mother can be reached, may still provide some small benefits for instant function.’ (viii)

- ‘The prevalence of clinical vitamin A deficiency (VAD) is quite low. For the last years in which information is available on children in Asia, it ranged from 0.5 percent in Sri Lanka to 4.5% in Bangladesh. Other age groups are affected as well, especially pregnant and lactating women. A prevalence of >1% indicates a public health problem.’ (viii)

- ‘Populations with the highest prevalence of VAD consume low amounts of animal products and fruits rich in beta-carotene.’ (viii)

- ‘High-dose vitamin A supplementation reduced mortality from diarrhea and measles by 23% for infants and for children age 6 months to 5 years.’ (ix)

- ‘Strong epidemiological evidence suggests a link between maternal and early childhood undernutrition and increased adult risk of various chronic diseases.’ (1)

- ‘Economic losses from undernutrition include, as percentages of total losses from all causes: foregone human productivity, 10-15%; foregone GDP, 5-10%; and losses in children’s disability-adjusted life years (DALYs), 20-25%.’ (4)

- ‘Improved nutrition is a particularly powerful antipoverty intervention because it can be achieved at low cost and it has a lifelong impact. In terms of a propoor, economic growth strategy that is sustainable, investment in nutrition is one of the best options.’ (4)

- ‘Many non-nutrition or indirect interventions, such as immunization and sanitation, have significant nutrition effects but these are beyond the scope of this review.’ (5)

- ‘Infants who weight 2,000-2,499 g at birth have a four-fold higher risk of neonatal death than those who weight 2,500-2,999 g, and a ten-fold higher risk than those weighing 3,000-3,499 g.’ (7)

- ‘In The Gambia, being born during and up to two months after the so-called ‘hungry season’ was a strong predictor of mortality after age 15 years. Being born in the hungry season was also associated with about a four-fold greater risk of dying between the ages of 15 and 45 years, and a ten-fold greater risk of dying between the ages of 35 and 45 years.’ (7-8)

- ‘Body Mass index is defined as weight (in kg) divided by height (in m) squared.’ (11)

- ‘Maternal height, although it contributes to total maternal mass, has less value than weight or BMI for predicting IUGR. Low height is a good indicator of obstetric complications such as obstructed labor and need for assisted delivery. It is therefore useful to refer short women to appropriate childbirth facilities.’ (12)

- ‘Evidence for an effect of iron supplements on preterm delivery and birthweight is still weak, due to a lack of randomized controlled trials.’ (14)

- ‘Folic acid taken prior to conception and during the first six weeks of pregnancy does afford some protection against neural tube defects.’ (14)

- ‘Cochrane meta-analyses found no effects of zinc supplementation on labor outcomes or on maternal or fetal mortality or morbidity.’ (14)

- ‘Calcium supplementation during pregnancy reduces the risk of hypertension, pre-eclampsia and eclampsia, and lowers the blood pressure of the neonate.’ (15)

- ‘A comprehensive review of 24 non-nutritional pregnancy interventions found that only two improved birthweight. These were smoking cessation, which improved birthweight and lowered term LBW by about 20%, and antimalarial prophylaxis.’ (16)

- ‘There remains little evidence that growth retardation suffered in early childhood can be significantly caught up in adolescence.’ (18)

- ‘IUGR may produce some prenatal insults to the fetal reproductive system that damages future reproduction, manifesting itself a generation later.’ (19)

- ‘LBW is probably the main reason why over 50% of the children in Asia are underweight.’ (21)

- ‘Young maternal age at conception is an additional risk factor for poor pregnancy outcome so that it is also important to target interventions to those who are still growing.’ (22)

- ‘The most common immediate causes of poor growth of humans in developing countries include: poor nutrition status at conception and undernutrition in utero; inadequate breastfeeding; delayed complementary feeding, inadequate quality or quantity of complementary feeding; impaired absorption of nutrients due to intestinal infections or parasites; or combinations of these problems.’ (24)

- ‘Interactions between inadequate dietary intake a disease, in the form of a vicious cycle, have been referred to as the ‘malnutrition-infection complex.’ Strictly speaking, however, it is a complex between the two immediate causes, with undernutrition being the outcome. This complex remains the most prevalent public health problem in the world today.’ (26)

- ‘The short stature of adults in developing countries is largely the result of poor growth during the first three years of life.’ (27)

- ‘Complementary feeding is defined as the period during which foods or liquids are provided along with continued breastfeeding. Complementary food is the term used to describe any nutrient-containing foods or liquids, other than breastmilk, that are given to young children during the period of complementary feeding.’ (29)

- ‘One strategy for improving the amount and bioavailability of micronutrients is to increase consumption of animal products. Animal products are high in most micronutrients, and many minerals and vitamins are better absorbed from milk, meat and eggs than they are from plant-derived foods.’ (33)

- ‘A dramatic example of the effects of withholding animal products from infants and young children is provided by studies of macrobiotic diets in the Netherlands. This example is particularly valuable because macrobiotic diets are somewhat similar to the diets of children in developing countries, and indeed are better than many. They consist primarily of cereals (mainly rice), vegetables, legumes, and marine algae, small amounts of cooked fruit and occasional fish. No meat or dairy products are used…Children from families consuming dairy products three times a week grew better than those who rarely consumed them. The macrobiotic infants showed numerous biochemical abnormalities and nutrient deficiencies, including: iron, with consequent anemia; riboflavin deficiency; rickets; and vitamin B deficiency. Their gross motor development, speech and language development were delayed. Recent publications show that the vitamin B₁₂ status and cognitive function of these children was still impaired in early adolescence, in spite of the fact that parents heeded advice to feed animal products, starting at 6 years on average.’ (33)

- ‘Given the poor economic situation of many households in developing countries, is it reasonable to recommend that their children consume more animal products? For some, this may not be a practical solution. There is, however, increasing awareness that animal products are likely [sic] be the only unfortified foods that can provide enough micronutrients to children, and that it is feasible to increase their consumption. Viable strategies, in many situations, include: educating the mother to target small amounts of animal products (such as liver) to her youngest children; encouraging consumption of cheaper animal products (e.g., eggs, fish, dried milk); and supporting home production of small animals, fish and birds.’ (34)

- ‘The absorption of iron from cereals and legumes can be improved by consuming more vitamin C in the same meal.’ (34)

- ‘In developing countries, iron deficiency occurs early in infancy, and approximately 50% of infants are iron deficient by the end of their first year of life.’ (36)

- ‘Interventions with single micronutrients have shown the following benefits for children with low intakes and/or a deficiency of the respective nutrients: vitamin A prevents eye lesions, causes a substantial reduction in mortality from measles and diarrhea, and increases Hb synthesis; iron improves cognitive and motor development of anemic infants and children; zinc improves growth of children who are stunted or have low plasma zinc. Iodine reduces infant mortality and goiter prevalence and improves motor and mental function; vitamin B₁₂ improves growth and cognitive function.’ (40)

- ‘Anemia is usually caused by lack of iron, the most common nutrient deficiency.’ (43)

- ‘Malaria and hookworm, the major non-nutrition risk factors for anemia, affect both men and women.’ (43)
- ‘The WHO estimated that about 40% of the world’s population (more than 2 billion individuals) suffer from anemia.’ (43)

- ‘The prevalence of anemia in developing countries is about four times that of developed countries.’ (43)

- ‘Women have a substantially higher prevalence of anemia than men, because about half of their iron requirement is needed to replace iron losses in menstruation.’ (44)

- ‘A major cause of anemia is infection with malaria or other parasites…In tropical Africa, for example, malaria and anemia explain the majority of visits to health centers. In Tanzania, malaria causes about 60% of the anemia, and iron deficiency only 30%.’ (44)

- ‘It is usually considered unethical to withhold iron during pregnancy where there is a high prevalence of anemia. Therefore, randomized, controlled trials are rare, especially in developing countries.’ (45)

- ‘A substantial amount of evidence confirms that iron supplementation of anemia school children improves their school performance, verbal and other skills.’ (48)

- ‘There has been considerable interest in the possibility that iron supplements do not have to be given as frequently as once a day to be effective.’ (48)

- ‘One way to improve the absorption of iron from food is to increase the intake of vitamin C. This enhances the absorption of non-hem iron if the two nutrients are consumed within an hour of each other.’ (50)

- ‘Of all of the strategies used to deliver additional iron to humans, food fortification has the greatest potential to improve the iron status of the largest number of people.’ (51)

- ‘Iron fortification poses no risk for the normal individual. Iron absorption falls, as iron stores increase, to protect against excessive iron accumulation...Overall, it is true that: ‘the potential benefit of an iron intervention to a predominantly iron-deficient population is likely to vastly outweigh any risk this may pose for a few individuals.’ ’ (53)

- ‘Weekly delivery of iron supplements does improve iron status, almost as well as daily delivery in the case of children and adolescents. This programmatic approach may be a cheaper, more effective way to prevent iron deficiency. Ways should be sought to deliver weekly iron through schools, community-based programs and other situations. However, daily supplements are still more effective for pregnant women because of their high iron requirements and the limited window of time available for supplementation.’ (54)

- ‘The main cause of iodine deficiency in soils is leaching by glaciation, floods or high rainfall. Mountainous regions including the Andes and the Himalayas therefore have some of the highest prevalences of iodine deficiency. Iodine deficiency also occurs due to flooding; for example, in Bangladesh and in India around the Ganges. In areas of endemic iodine deficiency, the water and foods (plants and animals grown there) have low iodine content.’ (55)

- ‘Goiter itself is unsightly but usually harmless. Importantly, its presence indicates that other damaging effects of iodine deficiency are already present.’ (56)

- ‘Iodine deficiency is the leading cause of preventable mental retardation and brain damage worldwide.’ (56)

- ‘Mean cognitive and psychomotor performance scores were 13.5 IQ points lower in iodine deficient individuals.’ (56)

- ‘The injection of iodized oil before pregnancy can prevent endemic cretinism.’ (57)

- ‘Iodine supplementation during pregnancy results in a substantial reduction in fetal and neonatal deaths.’ (58)

- ‘The public health benefits of salt iodization, however, far outweigh risks from toxicity.’ (58)

- ‘The main cause of VAD is a low intake of animal products, which contain high amounts of absorbable retinol. Liver and kidneys are a concentrated source of vitamin A.’ (61)

- ‘Some randomized, placebo-controlled trials in pregnant women show that pregnancy outcomes may be improved in HIV women if they receive high dose vitamin A.’ (64)

- ‘A review of food-based strategies recognized three main types: increase production of micronutrient-rich foods, from either commercial or home gardening, small livestock or aquaculture; increase intake of micronutrient-rich foods through nutrient education, mass media and other programs intended to change food selection; and improve nutrient bioavailability, by food processing or the simultaneous consumption of enhancing foods.’ (64-65)

- ‘Based on lessons from multiple experiences that achieved significant impacts on child nutrition, the following technical elements of growth promotion are essential for designing new programs and for assessing existing operations: programs should be community- or neighborhood-based, and aimed at universal coverage; monitoring individual weight begun at birth and done frequently (monthly) for the first 18-24 months; child caretakers involved in monitoring; adequate growth (weight gain), rather than nutrition status, as the indicator of action, either alone of combined with other easily obtained information on the child’s condition; growth charts to record the growth progress of individual children, to make growth status visible to the caretakers; analysis of the causes of inadequate growth is required, leading to clear and feasible options for action; negotiation with families, guided by tailored recommendations for what they will do to improve their children’s growth; and follow-up.’ (70)

- ‘Combined interventions are likely to be more efficient than separate interventions, because they are intended for the same population and make use of the same facilities, transportation and client contacts. From an economic standpoint, the marginal costs of integrated programs, that combine interventions are expected to be low, relative to impact.’ (71)

- ‘Example of a job description for a community growth promoter: Maintain a roster of all children under two in the community-enrolling children at birth. Organize a monthly weighing of all under-2s in a community, ensuring 100% participation. Assist each mother in weighing her child and plotting the weight on the growth chart. Help the mother to interpret the growth pattern and diagnose the problem, if there is one. Depending on the result and a discussion with the mother about causes, refer her to the appropriate program activities, including health consultation and supplementary food. Counsel her on one or two activities that she can do at home to help her child. Make home visits to children not growing well to provide more encouragement to the mother. Organize and participate in community meetings to analyze the growth of the community’s children and motivate collective action by the community. Help different groups organize specific activities. Hold group education sessions on common problems that mothers face in caring for their children. For some workers, managing records, food, cases of diarrhea, or coordinating with the health center might be part of the job description.’ (71)

- ‘Supplementary foods should be culturally acceptable and should permit the preparation of meals which are digestible, palatable, energy dense, and micronutrient rich, without being bulky. Other important prerequisites include: cost-effectiveness in closing the nutrient gaps of recipients; reliability of supply; feasibility of transport, storage and processing; short cooking time; low fuel costs; and adequate shelf life. The choice of local versus external production should be based on such criteria.’ (79)

- ‘Important nutrition-relevant, complementary actions, aimed at young children, include: growth monitoring and promotion; protection and promotion of breastfeeding and appropriate complementary feeding practices; immunization; disease management, including oral rehydration therapy; micronutrient supplementation; and deworming.’ (80)

- ‘A breakfast or morning snack is generally better than lunch, for alleviating hunger and achieving learning objectives.’ (80)

- ‘Deworming can have a high payoff for school children. Helminth burdens are most intense during the years of schooling.’ (81)

- ‘Iron supplementation and deworming have the lowest cost/DALY in school health programs.’ (81)

- ‘The reasons for dropout from a supplementation program are more likely to be related to poor supply and availability of the tablets than to side-effects.’ (83)

- ‘Supplements should be promoted positively as ‘health-promoting’ rather than negatively as ‘disease-curing.’ ’ (84)

- ‘It was also necessary to pass appropriate legislation to ensure correct levels of salt iodization, and to protect iodized salt producers by eliminating noniodized salt from the market.’ (86)

- ‘Costs per death averted by breastfeeding promotion and IEC are estimated as $100-300 in the poorest countries.’ (91)

- ‘Contextual success factors: Political commitment at all levels of society was considered essential for social mobilization at the start of the program or project and for future sustainability. The integration of nutritional goals in development programs in general is a clear manifestation of genuine awareness and political commitment…A culture where people, particularly women, are involved in decision making was a prerequisite for people’s participation and the creation of articulate bottom-up demands. A high level of literacy, especially among women, also associated strongly with participation and organizational capabilities…The parallel implementation of poverty-reducing programs, particularly those integrated with nutrition-oriented program/project.’ (93)