Progress through Policy

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“Red tape will often get in your way. It’s one of the reasons I often carry scissors.” – Richard Branson

The lack of harmonized regulations and standards prevents the most vulnerable populations from accessing high-quality and affordable nutritional products like MMS. Photo Credit: Vitamin Angels

Several low- and middle-income countries that see significant levels of maternal anemia and low birth weight newborns are considering the introduction and scale-up of Multiple Micronutrient Supplements, or MMS, to provide mothers the nutrients they need for healthy pregnancies. This is an admirable goal, albeit one that is frustratingly impeded by significant regulatory challenges. For example, there is little consensus on how a nutritional product is classified in different countries or by international agencies; it can be considered either a dietary supplement and regulated as a food or a therapeutic product regulated as a drug. In addition, regulatory agencies worldwide set different manufacturing requirements and quality standards for nutritional products, which are not always harmonized. This then presents challenges when a nutritional supplement is imported into or manufactured in countries with different regulation levels, ultimately preventing the most vulnerable populations from accessing high-quality and affordable products with the potential to improve health outcomes significantly.

A country’s food system is an equally complex machine, with the interplay between farmers, consumers, regulators, testers, manufacturers, and distributors. Inefficiencies or problems anywhere in this ecosystem can cause a domino effect felt along the value chain. Sadly, authorities in many countries in the Global South currently lack the capacity to create and enforce regulatory frameworks conducive to providing safe, nutritious, and accessible foods. Many producers also struggle to comply with the regulatory frameworks in place due to a lack of testing capacity and compliance support, leading to products that do not meet national or international standards or align with label claims.

There are systemic hurdles to delivering proper nutrition to those who need it. What can be done?

One of the most important steps in inducing a transformational change in food systems is integrating nutrition in sectors beyond public health, bringing private sector players into the nutrition fold. How can governments achieve this? Let us take the example of large-scale staple food fortification in India, such as rice or edible oil. Given that fortified variants are usually slightly more expensive to produce than unfortified products, voluntary fortification does not present a strong business case for the private sector, and compliance can quickly evaporate when there is a change of corporate management or leadership in the governing body—making fortification mandatory would increase compliance. The government is also poised to assist companies by educating their citizens on the health benefits of choosing a fortified food. This assistance, or “carrot”, creates a market incentive to balance the “stick” of mandatory regulation.

 

The Indian government roped in the most popular cricketer in the country, Virat Kohli, for a brand-agnostic campaign to create a consumer pull for fortified foods and incentivize the private sector to sustainably introduce fortified variants in the market. Source: Food Fortification Resource Centre

As demonstrated by this example, government regulators and the private sector can find ways to support the health of their population and consumers in a coordinated manner.

The challenges highlighted earlier can seem intractable, but Sight and Life believes that a new initiative can lead to real progress – Food Systems Innovation Hubs. These hubs, which will operate in rapidly emerging economies in need of regulatory assistance, can share expertise and resources to foster capacity-development and address existing gaps in regulations and standards. They will also provide testing monitoring support to allow producers and processors to improve the quality of their output. The Food System Innovation Hubs will focus on accelerating technology transfer, and investment from the Global North to the Global South, enabling the kind of knowledge sharing that can contribute to increased standardization across borders.

Everyone benefits when food systems prioritize good health.
 

Food Systems Innovation Hubs are a bold, new initiative that will accelerate innovation, streamline processes, and support nature-positive, biodiverse agriculture to better nourish the nations and communities they serve.  Join us in this coordinated effort to improve the world’s food systems. We welcome you to bring your unique skills and resources to bear in helping solve these unique challenges.

Watch this engaging webinar discussing the importance of a Food Systems Innovation Hub and be part of the coordinated effort to improve the world’s food systems. Read further on the topic by clicking HERE

Opinion: Engaging nutrition to improve pregnancy outcomes

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On December 17, 2019, Devex published “Opinion: Engaging nutrition to improve pregnancy outcomes” by Klaus Kraemer, managing director of Sight and Life and adjunct associate professor at the Johns Hopkins Bloomberg School of Public Health. The full article can be read here on Devex.

Abstract

Good nutrition sets off a ripple effect. It can dismantle inequity, poverty, and poor health and drive progress at every stage in life. It supports physical and cognitive development, helps prevent a number of medical conditions — from spina bifida to diabetes — and saves lives.

During and after pregnancy, nutrition demands are greater — as are the consequences of not meeting them. For mothers, ensuring a healthy pregnancy limits the risk of life-threatening complications. And for their children, good nutrition during pregnancy can be the difference between being born healthy and being born physically or mentally disadvantaged.

It is critical that we sustain our momentum on nutrition, a task that requires greater investment in cultivating a cadre of leaders to take us there, argues Klaus Kraemer, director at Sight and Life.

While diet diversity remains the preferred means for women to meet nutrient requirements during pregnancy, many nutrient needs cannot be met through diet alone, especially in resource-constrained settings. As such, it is imperative that we reach women and girls with effective interventions for improving maternal nutrition that are ready for global scale-up now. Multiple micronutrient supplementation, or MMS, during pregnancy could be one way to help meet maternal nutrition needs.

Read the full article on Devex here.

Changing the Standard

Why Multiple Micronutrient Supplements in Pregnancy Are an Ethical Issue

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On 9 July 1999, the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the United Nations University (UNU) held a technical workshop at the UNICEF headquarters in New York to address widespread micronutrient deficiencies and high rates of anemia among pregnant women. Looking beyond iron and folic acid (IFA), the workshop designed a comprehensive prenatal supplement – or multiple micronutrient supplement (MMS) –that would be tested in effectiveness trials among pregnant women in low- and middle-income countries (LMICs). Thus, the United Nations International Multiple Micronutrient Antenatal Preparation – now commonly known by its acronym, UNIMMAP – was born.

Women, Family, children

The group at the workshop was, in many ways, before its time. They identified access to MMS as an inequity issue as stated in a report the group published after the workshop: “The high [micronutrient] needs of pregnancy are almost impossible to cover through dietary intake [alone] – in most industrialized countries, it is common for women to take multiple micronutrient supplements during pregnancy and lactation.” And the group discussed how MMS could impact other at-risk groups, particularly adolescent girls.
 
They also considered the needs of the women most in need – and reflected on the information at their fingertips. The UNIMMAP formulation consisted of1 RDA (Recommended Dietary Allowance for women 19-50 years during pregnancy and lactation) for 15 essential vitamins and minerals. But they correctly predicted that 1 RDA underestimated the requirements for populations in LMICs because they were based on dietary reference intakes from populations in the US and Canada, where nutritional statuses are stronger. In April, results from the JiVitA-3 study in rural Bangladesh (the largest ever trial comparing prenatal MMS to IFA) showed that 1 RDA, while reducing risks of preterm birth, low birth weight and still birth, and while improving micronutrient status, failed to eliminate deficiencies. Might 2 RDAs have had a greater effect on birth outcomes in an environment where poverty, poor diets and frequent infections prevail?

The bigger picture

Malnutrition – undernutrition, overweight, obesity, and micronutrient deficiencies – is a driver of intergenerational inequity, poverty, and poor health. It represents a significant barrier to equitable and sustainable social and economic development, in high- and low-income countries alike. However, many women and girls lack access to essential antenatal and postnatal care services, including micronutrient supplementation. This is especially true for women living in LMICs. While 62% of pregnant women globally receive at least four antenatal care visits, in regions with the highest rates of maternal mortality – such as sub-Saharan Africa and South Asia – only 52% and 46% of women in the respective regions receive the same services. Further coverage disparities exist between poor and rich, and rural and urban households. In South Asia and sub-Saharan Africa, the urban-rural gap in coverage of antenatal care visits exceeds 20 percentage points in favor of urban areas, and the richest 20% of the population are more likely to receive antenatal care than poorer women. Good nutrition and equitable rights for all women are mutually reinforcing, and with improved gender equality leading in turn to improved nutrition.

We see this uneven and sub-optimal maternal care reflected in infant birthweight. A new study by the London School of Hygiene & Tropical Medicine (LSHTM), the WHO, and UNICEF finds that there has been minimal progress on reducing the number of babies born low birthweight (LBW), meaning they weigh less than 2,500 grams (5.5 pounds) at birth – a cause for alarm given that LBW increases the risk of newborn death, stunted growth, developmental delays, and conditions such as heart disease and diabetes later in life. As the mother’s micronutrient requirement increases during pregnancy in order to support the growth of the fetus, maternal undernutrition during pregnancy is closely linked with LBW.In 2015, 14.6% of all births worldwide, or 20.5 million babies, were born with LBW, the majority in sub-Saharan Africa and South Asia. Urgent action is needed to get the world on track to meet global goals on LBW, and maternal nutrition must be at the center of this effort.

Time for a change

To help meet women’s increased nutritional demands during pregnancy, the WHO recommends IFA as the current standard of care for pregnant women – but the policy has not changed in 50 years. The most recent 2016 WHO Antenatal Care (ANC) Guidelines, however, opened a window for MMS. The guidelines counsel against the use of MMS due to “some evidence of risk, and some important gaps in evidence,” but stipulate that “policymakers in populations with a high prevalence of nutritional deficiencies might consider the benefits to outweigh the disadvantages [such as cost], and may choose to give multiple micronutrient supplements that include iron and folic acid.”
 
Since 2016, the scientific community has met all the WHO’s concerns regarding risk and evidence. Compelling scientific evidence shows that taking MMS during pregnancy reduces the risk of maternal anemia and reduces the likelihood of a child being born LBW and too small. Anemic and underweight women benefit even more from MMS and have reduced risk of infant mortality and preterm births compared with mothers taking only IFA. Furthermore, recent research shows that MMS can reduce the gender imbalance in terms of the survival of female neonates compared with IFA supplementation alone, and that it represents an opportunity to invigorate maternal nutrition by putting women at the center of antenatal care.

The push for progress

The Women Deliver Conference (Vancouver, 3–6 June 2019) will be the world’s largest conference on gender equality, so Sight and Life and other leading organizations are working to elevate MMS. At Women Deliver, Sight and Life has partnered with the Children Investment Fund Foundation (CIFF), Kirk Humanitarian, 1,000 Days, Vitamin Angels, and the Multiple Micronutrient Supplement Technical Advisory Group (MMS TAG) – to host a side-event to make the case for MMS and build support behind the movement to update the global recommendations on MMS. This event, named Power for Mothers, will capitalize on the gathering of global leaders, key influencers, decision-makers, civil society and donors as part of the Women Deliver conference.

I firmly believe that, after 20 years of research and some 20 studies and meta-analyses comparing IFA and MMS on birth outcomes, it is unethical to further withhold MMS from pregnant women in low-resource settings. The MMS TAG (to which I belong) has documented the clear scientific advantage of MMS over IFA and the safety of MMS for mothers and their children, and has shown that the provision of prenatal MMS is a cost-effective intervention. Not only is MMS cost-effective, but it has also achieved cost parity.
 
It is no wonder why some early-riser countries with widespread micronutrient deficiencies have requested implementation research and donations of MMS for the successful replacement of IFA in their health sector. The time is now to adapt global and national guidelines to the overwhelming evidence. Disparities in antenatal care including the provision of MMS are no longer acceptable.

Email: klaus.kraemer@sightandlife.org