Decreasing Stunting,Anemia,and Vitamin A Deficiency in Peru: Results of the Good Start in Life Program

Abstract

Background

The rates of stunting, iron-deficiency anemia, and vitamin A deficiency in Peru are among the highest in South America. There is little scaled-up experience on how to solve these problems countrywide.

Objective

To evaluate the Good Start in Life Program during the period from 2000 to 2004.

Methods

Data on weight, height, hemoglobin, serum retinol, urinary iodine, and age were obtained from children under 3 years of age during two transverse surveys in 2000 and 2004.

Results

In 2004, the program covered 75,000 children, 35,000 mothers, and 1 million inhabitants from 223 poor communities. The rate of stunting decreased from 54.1% to 36.9%, the rate of iron-deficiency anemia decreased from 76.0% to 52.3%, and the rate of vitamin A deficiency decreased from 30.4% to 5.3% (p < .01). The annual cost per child was US$116.50.

Conclusions

Adaptations of this participative program could contribute to decreased stunting, iron-deficiency anemia, and vitamin A deficiency at the national scale in Peru and many other countries.

Keywords

Children cost early stimulation effectiveness Good Start in Life Program iron-deficiency anemia Peru stunting vitamin A deficiency

References

UNICEF. State of the world's children 2007. New York: UNICEF, 2007.

Gross

Lechtig

López de Romaña

. We know much about what to do but little about how to do it: Experiences with a weekly multimicronutrient supplementation campaign. Food Nutr Bull 2006;27(suppl):111–4.

Gobierno del Perú. Ministerio de Economía y Finanzas. Estadísticas económicas. Tipo de Cambio. November 2006. Available at: http://www.mef.gob.pe. Accessed 16 August 2008.

UNICEF Peru. Proyecto supervivencia crecimiento y desarrollo temprano. Cooperación UNICEF-USAID “Iniciativa Buen Inicio.” Reporte de resultados finales e intermedios 2000–2004. November 2005.

Lechtig

. Evaluación externa del Programa Buen Inicio en la Vida. Lima: UNICEF, 2007.

Ministerio de Salud. Instituto Nacional de Salud, Centro Nacional de Alimentación y Nutrición. La medición de la talla y el peso. Guía para el personal de la salud del primer nivel de atención. Lima: Ministerio de Salud, 2004.

Neufeld

Garcia-Guerra

Sanchez-Francia

Newton-Sanchez

Ramirez-Villalobos

Rivera-Dommarco

. Hemoglobin measured by HemoCue and a reference method in venous and capillary blood: A validation study. Salud Publica Mex 2002;44:219–27.

Morris

Ruel

Cohen

Dewey

de la Briere

Hassan

. Precision, accuracy, and reliability of hemoglobin assessment with use of capillary blood. Am J Clin Nutr 1999;69:1243–8.

Catignani

Bieri

. Simultaneous determination of retinol and α-tocopherol in serum or plasma by liquid chromatography. Clin Chem 1983;29:708–12.

10.

Pino

Fang

Braverman

. Ammonium persulfate: A safe alternative oxidizing reagent for measuring urinary iodine. Clin Chem 1996;42:239–242.

11.

SPSS for Windows, version 11.0.

12.

UNICEF. The nutrition strategy. New York: UNICEF, 1990.

13.

Gross

Lechtig

López de Romaña

. Baseline evaluation of nutritional status and government feeding programs in Chiclayo, Peru. Food Nutr Bull 2006;27(suppl):115–21.

14.

UNICEF Peru. La exclusión social en el Perú. Lima: UNICEF, 2001.

15.

Jennings

Scialfa

Gillespie

Lotfi

Mason

. Managing successful nutrition programmes. ACC/SCN State-of-the-Art Series Nutrition Policy Discussion Paper No. 8. Geneva: Administrative Committee on Coordination/Sub-Committee on Nutrition, 1991.

16.

Gillespie

Mason

Martorell

. How nutrition improves. ACC/SCN State-of-the-Art Nutrition Policy Discussion Paper No. 15. Geneva: Administrative Committee on Coordination/Sub-Committee on Nutrition, 1996.

17.

Kedamo

Kereta

Winch

. Community assessment and planning for maternal and child health programs: A participatory approach in Ethiopia. BASICS Technical Report. Washington, DC: US Agency for International Development, 1998.

18.

CARE Peru. REDESA: Buenas prácticas de lavado de manos. En el Callejón de Huaylas y Conchucos 2003–2004. Lima: CARE Peru, 2005.

19.

World Health Organization nutrition web page. Available at: http://www.who.int/nut. Accessed 16 August 2008.

20.

World Health Organization. The World Health Report 2002: Reducing risks, promoting healthy life. Geneva: WHO, 2002.

21.

US Department of Agriculture/Human Development Network/World Bank/UNICEF. Technical Consultation on low birthweight. New York: UNICEF, 2000.

22.

Becker

Lechtig

. Increasing poverty and infant mortality in the Northeast of Brazil. J Trop Pediatr 1987;33:58–9.

23.

Pojda

Kelley

, eds. Low birthweight. A report based on the International Low Birthweight Symposium and Workshop held 14–17 June 1999 in Dhaka, Bangladesh. ACC/SCN Nutrition Policy Paper No. 18. Geneva: Administrative Committee on Coordination/SubCommittee on Nutrition, 2000.

24.

Villar

Smeriglio

Martorell

Brown

Klein

. Heterogeneous growth and mental development of intrauterine growth-retarded infants during the first 3 years of life. Pediatrics 1984;74:783–91.

25.

Ashworth

. Effects of intrauterine growth retardation on mortality and morbidity in infants and young children. Eur J Clin Nutr 1998;52:S34–42.

26.

Rasmussen

. The “fetal origins” hypothesis: Challenges and opportunities for maternal and child nutrition. Annu Rev Nutr 2000;2:73–95.

27.

UNICEF. Facts for life, 3rd ed. New York: UNICEF, 2002.

28.

Lutter

Perez-Escamilla

Segall

Sanghvi

Teruya

Wickham

. The effectiveness of a hospital-based program to promote exclusive breast-feeding among low-income women in Brazil. Am J Public Health 1997;87:659–63.

29.

Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, Collet JP, Vanilovich I, Mezen I, Ducruet T, Shishko G, Zubovich V, Mknuik D, Gluchanina E, Dombrovskiy V, Ustinovitch A, Kot T, Bogdanovich N, Ovchinikova L, Helsing E; PROBIT Study Group (Promotion of Breastfeeding Intervention Trial). Promotion of Breastfeeding Intervention Trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA 2001;285:413–20.

30.

Horton

Sanghvi

Phillips

Fiedler

Perez-Escamilla

Lutter

Rivera

Segall-Correa

. Breastfeeding promotion and priority setting in health. Health Policy Plan 1996;11:156–68.

31.

Morrow

Guerrero

Shults

Calva

Lutter

Bravo

Ruiz-Palacios

Morrow

Butterfoss

. Efficacy of home-based peer counselling to promote exclusive breastfeeding: A randomised controlled trial. Lancet 1999;353:1226–31.

32.

Haider

Ashworth

Kabir

Huttly

. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: A randomised controlled trial. Lancet 2000;356:1643–8.

33.

Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK, Infant Feeding Study Group. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: A cluster randomised controlled trial. Lancet 2003;361:1418–23.

34.

Aidam

Perez-Escamilla

Lartey

. Lactation counseling increases exclusive breast-feeding rates in Ghana. J Nutr 2005;135:1691–5.

35.

Anderson

Damio

Young

Chapman

Perez-Escamilla

. A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. Arch Pediatr Adolesc Med 2005;159:836–41.

36.

Dearden

Altaye

De Maza

De Oliva

Stone-Jimenez

Burkhalter

Morrow

. The impact of mother-to-mother support on optimal breast-feeding: A controlled community intervention trial in periurban Guatemala City, Guatemala. Rev Panam Salud Publica 2002;12:193–201.

37.

Chapman

Damio

Young

Perez-Escamilla

. Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina population: A randomized controlled trial. Arch Pediatr Adolesc Med 2004;158:897–902.

38.

Perez-Escamilla

. Breastfeeding and the nutritional transition in the Latin American and Caribbean Region: A success story? Cad Saude Publica 2003;19(suppl 1):S119–27.

39.

Rea

. A review of breastfeeding in Brazil and how the country has reached ten months' breastfeeding duration. Cad Saude Publica 2003;19(suppl 1):S37–45.

40.

Armstrong

. Breastfeeding as the foundation of care. Food Nutr Bull 1995;16:299–312.

41.

Engle

. The role of caring practices and resources for care in child survival, growth, and development: South and Southeast Asia. Asian Dev Rev 1999;17:132–67.

42.

Engle

Bentley

Pelto

. The role of care in nutrition programmes. Proc Nutr Soc 2000;59:25–35.

43.

Engle

Lhotska

Armstrong

. The care initiative: Assessment, analysis and action to improve care for nutrition. New York: UNICEF, 1997.

44.

World Health Organization. Complementary feeding: Family foods for breastfed children. Geneva: WHO, 2000.

45.

World Health Organization. A critical link: Interventions for physical growth and psychological development: A review. Geneva: WHO, 1999.

46.

Brown

Dewey

Allen

. Complementary feeding of young children in developing countries: A review of current scientific knowledge. Geneva: World Health Organization, 1998.

47.

Dewey

. Approaches for improving complementary feeding of infants and young children. Background paper for the WHO/UNICEF Technical Consultation on Infant and Young Child Feeding. Geneva: World Health Organization, 2001.

48.

Stanbury

, ed. The damaged brain of iodine deficiency. New York: Cognizant Communications, 1994.

49.

Shrestha

West

. Role of iodine in mental and psychomotor development: An overview. Wageningen, Netherlands: Grafisch Service Centrum, 1994.

50.

Connolly

Pharoah

Hetzel

. Fetal iodine deficiency and motor performance during childhood. Lancet 1979;2:1149–51.

51.

Cobra

Muhilal

Rusmil

Rustama Djatnika Suward

Permaesih

Muherdiyantiningsih Marturi

Semba

. Infant survival is improved by oral iodine supplementation. J Nutr 1997;127:574–8.

52.

Huda

Gratham-McGregor

Rahman

Tomkins

. Biochemical hypothyroidism secondary to iodine deficiency is associated with poor school achievement and cognition in Bangladeshi children. J Nutr 1999;129:980–7.

53.

Beaton

Martorell

Aronson

. Effectiveness of vitamin A supplementation in the control of young childhood morbidity and mortality in developing countries. State-of-the-Art Series Nutrition Policy Discussion Paper No. 13. Geneva: Administrative Committee on Coordination/Sub-Committee on Nutrition, 1993.

54.

West

Jr Katz

Khatry

LeClerq

Pradhan

Shrestha

Connor

Dali

Christian

Pokhrel

Sommer

. Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta carotene on mortality related to pregnancy in Nepal. The NNIPS-2 Study Group. BMJ 1999;318: 570–5.

55.

Soleri

Cleveland

Wood

. Vitamin A nutrition and gardens bibliography, Vitamin A Field Support Project (VITAL) Report No. IN-I. Washington, DC: International Life Sciences Institute, 1991.

56.

Barclay

Foster

Sommer

. Vitamin A supplements and mortality related to measles: A randomised clinical trial. BMJ 1987;294:294–6.

57.

Sommer A, Rahmathullah L, Underwood B, Milton R, Reddy V, West K, Daulaire N, Stutkel T, Herrera G, Stansfield S, Ross D, Kirkwood BR, Arthur P, Morris S, Kjolhede C, Dibley M, Barreto M, Bhan MK, Gove S; the Vitamin A and Pneumonia Working Group. Potential interventions for the prevention of childhood pneumonia in developing countries: A meta-analysis of data from field trials to assess the impact of vitamin A supplementation on pneumonia morbidity and mortality. Bull World Health Organ 1995;73:609–19.

58.

Allen

. Anemia and iron deficiency: Effects on pregnancy outcome. Am J Clin Nutr 2000;71(suppl 5): S1280–4.

59.

Viteri

. The consequences of iron deficiency and anaemia in pregnancy on maternal health, the foetus and the infant. SCN News 1994;11:14–7.

60.

UNICEF/United Nations University/World Health Organization/Micronutrient Initiative. Preventing iron deficiency in women and children. Technical Consensus on key issues. Boston, Mass, USA/Ottawa, Canada: International Nutrition Foundation/Micronutrient Initiative, 1999.

61.

Stoltzfus

Albonico

Chwaya

Tielsch

Schulze

Savioli

. Effects of the Zanzibar school-based deworming program on iron status of children. Am J Clin Nutr 1998;68:179–86.

62.

Yip

Parvanta

McDonnell

Trowbridge

. CDC recommendations for the prevention and management of iron deficiency and iron overload. Atlanta, Ga, USA: Centers for Disease Control and Prevention, 1996.

63.

Ruel

Levin

. Assessing the potential for food-based strategies to reduce vitamin A and iron deficiencies: A review of recent evidence. Food Consumption and Nutrition Division Discussion Paper No. 92. Washington, DC: International Food Policy Research Institute, 2000.

64.

Lozoff

Jimenez

Wolf

. Long-term developmental outcome of infants with iron deficiency. N Engl J Med 1991;325:687–94.

65.

Lozoff

Wolf

Jimenez

. Iron-deficiency anemia and infant development: Effects of extended oral iron therapy. J Pediatr 1996;129:382–9.

66.

Moffatt

Longstaffe

Besant

Dureski

. Prevention of iron deficiency and psychomotor decline in high-risk infants through use of iron-fortified infant formula: A randomized clinical trial. J Pediatr 1994;125:527–34.

67.

Idjradinata

Pollitt

. Reversal of developmental delays in iron-deficient anaemic infants treated with iron. Lancet 1993;341:1–4.

68.

Palupi

Schultink

Achadi

Gross

. Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation. Am J Clin Nutr 1997;65:1057–61.

69.

Scholz

Gross

Schultink

Sastroamidjojo

. Anaemia is associated with reduced productivity of women workers even in less-physically-strenuous tasks. Br J Nutr 1997;77:47–57.

70.

Grantham-McGregor

Ani

. A review of studies on the effect of iron deficiency on cognitive development in children. J Nutr 2001;131(2S-2): 649S–66S; discussion 666S–8S.

71.

Draper

. Child development and iron deficiency: The Oxford Brief. Washington, DC: US Agency for International Development/Opportunities for Micronutrient Interventions/Partnership for Child Development, 1997.

72.

Ross

Thomas

. Iron deficiency anemia and maternal mortality. Washington, DC: Academy for Educational Development, 1996.

73.

Brabin

Hakimi

Pelletier

. An analysis of anemia and pregnancy-related maternal mortality. J Nutr 2001;131:S604–15.

74.

Allen

. Anemia and iron deficiency: Effects on pregnancy outcome. Am J Clin Nutr 2000;71(suppl 5): S1280–4.

75.

Viteri

. The consequences of iron deficiency and anaemia in pregnancy on maternal health, the foetus and the infant. SCN News 1994;11:14–7.

76.

Mata

Urrutia

Lechtig

. Infection and nutrition of children of a low socioeconomic rural community. Am J Clin Nutr 1971;24:249–59.

77.

Lozoff

Wolf

Jimenez

. Iron-deficiency anemia and infant development: Effects of extended oral iron therapy. J Pediatr 1996;129:382–9.

78.

UNICEF. The state of the world's children. Focus on malnutrition: Causes, consequences and solutions. New York: UNICEF, 1998.

79.

MacMahon

Pugh

. Epidemiology. Principles and methods. New York: Little, Brown and Company, 1970.

80.

Lechtig

Gross

Aquino

Gross

López de Romaña

. Lessons learned from the scaling-up of a weekly multimicronutrient supplementation program in the Integrated Food Security Program. Food Nutr Bull 2006;27(suppl):160–4.

81.

Yambi

Mlolwa

. Improving nutrition in Tanzania in 1980s: The Iringa experience. UNICEF International Child Development Centre. Innocenti Occasional Papers EPS 25. Florence, Italy: Spedale degli Innocenti, 1992.

82.

Ministerio de Salud del Perú. Instituto Nacional de Salud. Situación Nutricional del Perú. Available at: http://www.ins.gob.pe/gxpsites/hgxpp001.aspx?2,4,157,O,S,0,MNU;E;9;7;33;5;MNU. Accessed 16 August 2008.

83.

UNICEF New York/Administrative Committee on Coordination/Sub-Committee on Nutrition. What works? A review of the efficacy and effectiveness of nutrition interventions. Nutrition Policy Paper No. 19. Geneva: Asian Development Bank, 2001.

84.

Lechtig

Gross

Paulini

Lopez de Romaña

. Costs of the multimicronutrient supplementation program in Chiclayo, Peru. Food Nutr Bull 2006;27(suppl):151–9.

85.

UNICEF. Ministerio de Promoción de la Mujer y del Desarrollo Humano, Perú. XI Cumbre Iberoamericana de Jefes de Estado y de Gobierno. III Conferencia Iberoamericana de Ministras y Ministros y Altos Responsables de Infancia y Adolescencia. Fondo Editorial del Congreso del Perú. Lima, 2001. Lechtig A, Díaz Rangel A. M. Preparación del texto base de consenso.