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The Series identifies a set of ten provennutrition-specific interventions, which if scaled up

from present population coverage to cover 90% ofthe need, would eliminate about 900 000 deathsof children younger than 5 years in the 34 highnutrition-burden countries where 90% of theworlds stunted children live.

www.thelancet.comMaternal and Child Nutrition June, 2013

Maternal and Child Nutrition


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The LancetLondon32 Jamestown Road,London NW1 7BY,UKT +44 (0)20 7424 4910F +44 (0)20 7424 4911

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Comment

1 Nutrition: a quintessential sustainable development goalR Horton, S Lo

2 Maternal and child nutrition: building momentum or impactMaternal and Child Nutrition Study Group

5 Delivery platorms or sustained nutrition in EthiopiaF Lemma, J Matji

7 Only collective action will end undernutritionA Taylor and others

9 Nutrition-sensitive ood systems: rom rhetoric to actionP Pinstrup-Andersen

10 Global child and maternal nutritionthe SUN risesD Nabarro

12 Early nutrition and adult outcomes: pieces o the puzzleZ A Bhutta

Series

15 Maternal and child undernutrition and overweight in low-income andmiddle-income countriesR E Black and others

40 Evidence-based interventions or improvement o maternal and child nutrition:what can be done and at what cost?Z A Bhutta and others

66 Nutrition-sensitive interventions and programmes: how can they help to accelerateprogress in improving maternal and child nutrition?M T Ruel and others

82 The politics o reducing malnutrition: building commitment and accelerating progressS Gillespie and others

Articles

100 Mortality risk in preterm and small-or-gestational-age inants in low-income andmiddle-income countries: a pooled country analysisJ Katz and others

109 Associations o linear growth and relative weight gain during early lie with adulthealth and human capital in countries o low and middle income: fndings rom fvebirth cohort studiesL S Adair and others

Maternal and Child Nutrition June, 2013

Editor

Richard Horton

Deputy Editor

Astrid James

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www.thelancet.com 1

Nutrition: a quintessential sustainable development goalIn the nal paper o our 2008 Lancet Series on maternal

and child undernutrition, Saul Morris and colleagues

wrote that, The international nutrition systemmade

up o international and donor organisations, academia,

civil society, and the private sectoris ragmented

and dysunctional.1 They concluded that, incredibly,

no evidence base existed to prioritise actions to

improve nutrition. And they argued that the voice o

countries must be better heard, elt, and reected in

global decision making. Too oten country priorities

to strengthen nutrition were ignored by donors andagencies alike. 5 years on, thanks to the work o a

consortium o scientists led by Robert E Black rom

Johns Hopkins Bloomberg School o Public Health

(the Maternal and Child Nutrition Study Group), we

review the progress made against these ndings and

recommendations.26 Although some news is better

than 5 years ago, there is still a deeply worrying gul

between country needs and global actions. But what is

most dierentan extraordinary opportunity as well as

a severe challengeis the political urgency o nutrition.

This latest Lancet Series updates, with extensive

new data, the contribution undernutrition in itsvarious orms makes to child mortality and morbidity.

Compared with 2008, the result is a radically dierent

picture o the relation between nutritional deciencies

and child health. The overall nding is that 31 million

children younger than 5 years die every year rom

undernutrition; that is a staggering 45% o total child

deaths in 2011.

To address this enormous and too oten hidden cause

o child mortality, the Maternal and Child Nutrition

Study Group propose a new ramework to optimise

the delivery o priority evidence-based interventions

to prevent and treat undernutrition across the wholelie course. Unique to this Series is the systematic

approach to both the timing o the interventions and

to creating an enabling environment or nutrition. The

Maternal and Child Nutrition Study Group emphasises

ten interventions targeted to women o reproductive

age, during pregnancy, and to inants and children.

They calculate the eects o these interventions in

34 countries across Arica, Asia, and the Middle East,

where 90% o the global burden o undernutrition

resides. In doing so, they reinorce the importance o

the rst 1000 days rom conception to 2 years. What

goes right and what goes wrong or etal and child

nutrition during this period has lasting and irreversible

consequences or later lie.

There are several entirely new ndings in this Series.

First, the adolescent girl is identied as especially

vulnerable to the eects o undernutrition. But that very

predicament also makes adolescent girls a group with a

special opportunity too.

Second, the importance o etal growth restriction

or being born small or gestational age is highlighted.According to new estimates, etal growth restriction

causes more than 800 000 neonatal deaths and 20% o

stunting in children younger than 5 years worldwide.

These ndings are presented by Robert E Black and

colleagues,2 and Joanne Katz and colleagues7 in the

companion Article. Third, the Series is not only concerned

with interventions. It also identies delivery platorms

or the implementation o those interventions, most

promisingly in the community and in schools. Fourth,

the Series costs these interventions and explains why

those costsan additional Int$96 billion annually or

the 34 countries identiedare much less prohibitivethan they might at rst seem. And nally, the Series

identies a urther threat to maternal and child

nutritional status: overweight and obesity.

On June 8, 2013, the Governments o Brazil and the

UK will co-host a Nutrition or Growth event. There is

thereore an immediate opportunity to oster political

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June 6, 2013

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2 www.thelancet.com

Maternal and child nutrition: building momentum for impact

In the 5 years since the Maternal and Child Under-nutrition Series15 was published in The Lancet there

has been a substantial increase in commitment to

reduction o malnutrition at global and national

levels. Most development agencies have developed

or revised their strategies to address undernutrition

ocused on the rst 1000 days o liethe period rom

pregnancy to a childs second birthdayas called or in

the 2008 Series. One o the main drivers o this new

international momentum is the Scaling Up Nutrition

movement.6,7 National commitment in low-income

and middle-income countries (LMICs) is growing,donor unding is rising, and civil society and the

private sector are increasingly engaged.

Despite this progress, improvements in nutrition

still represent a massive unnished agenda. The

165 million children with stunted growth in 2011 have

compromised cognitive development and physical

capabilities, making yet another generation less pro-

ductive than they would otherwise be.8 Countries will

not be able to break out o poverty or sustain economic

advances when so much o their population is unable

support or the interventions that can be quickly scaledup or linked to nutrition programmessuch as early

child development initiatives. It is equally important to

take note o the message o Marie Ruel and colleagues 4

that in certain sectors, such as agriculture, the evidence

o the eect o targeted programmes on maternal and

child nutrition is largely inconclusive and requires new

approaches to eld evaluation.

Since 2008, there have been only limited increases in

donor aid or nutrition. It is true that nutrition is not

so readily attractive to politicians as an international

development priority. Undernutrition has a complex

set o political, social, and economic causes, none owhich are amenable to easy solutions that t within

the timerame o a single political cycle. For this reason,

the outlook today or nutrition is not wholly good. The

target endorsed only a year ago at the World Health

Assemblyto reduce by 40% the number o children

stunted by 2025is already on course to be missed.

As the endpoint o the Millennium Development

Goals approaches, countries and the international

community may agree that nutrition was one o the

great missed opportunities o the past 15 years. But this

neglect can be turned around quickly. As sustainable

development becomes the dominant idea post-2015,nutrition emerges as the quintessential example o a

sustainable development objective. I maternal and

child nutrition is optimised, the benets will accrue

and extend over several generations. This remarkable

opportunity is why Stuart Gillespie and colleagues5 take

a very dierent approach to implementation than in any

previous Lancet Series. Instead o exhorting politicians

and policy makers to do somethingor worse, simplyhoping that political commitment will appear like a

rabbit out o a hatthey set out a practical guide about

how to seize the agenda or nutrition, how to create

political momentum, and how to turn that momentum

into results. This is the prize we have to grasp in the next

18 months.

Richard Horton, Selina LoThe Lancet, London NW1 7BY, UK

We thank the Maternal and Child Nutrition Study Group, led by Robert E Black,

or leading the conception and design o this Series. We also acknowledge the

generosity o the Bill & Melinda Gates Foundation or providing nancial support.

1 Morris S, Cogill B, Uauy R, et al. Eective international action againstundernutrition: why has it proven so difcult and what can be done toaccelerate progress? Lancet 2008; 371: 60821.

2 Black RE, Victora CG, Walker SP, et al, and the Maternal and Child NutritionStudy Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; published online

June 6. http://dx.doi.org/10.1016/S0140-6736(13)60937-X.

3 Bhutta ZA, Das JK, Rizvi A, et al, The Lancet Nutrition Interventions ReviewGroup, and the Maternal and Child Nutrition Study Group. Evidence-basedinterventions or improvement o maternal and child nutrition: what canbe done and at what cost? Lancet 2013; published online June 6. http://dx.doi.org/10.1016/S0140-6736(13)60996-4.

4 Ruel MT, Alderman H, and the Maternal and Child Nutrition Study Group.Nutrition-sensitive interventions and programmes: how can they help toaccelerate progress in improving maternal and child nutrition?Lancet 2013; published online June 6. http://dx.doi.org/10.1016/S0140-6736(13)60843-0.

5 Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N, and the Maternal andChild Nutrition Study Group. The politics o reducing malnutrition:

building commitment and accelerating progress. Lancet 2013; publishedonline June 6. http://dx.doi.org/10.1016/S0140-6736(13)60842-9.

6 Maternal and Child Nutrition Study Group. Maternal and child nutrition:building momentum or impact. Lancet 2013; published online June 6.http://dx.doi.org/10.1016/S0140-6736(13)60988-5.

7 Katz J, Lee ACC, Kozuki N, et al, and the CHERG Small-or-Gestational-Age-Preterm Birth Working Group. Mortality risk in preterm and small-or-gestational-age inants in low-income and middle-income countries:a pooled country analysis. Lancet 2013; published online June 6. http://dx.doi.org/10.1016/S0140-6736(13)60993-9.

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www.thelancet.com 3

to achieve the nutritional security that is needed or ahealthy and productive lie. Undernutrition is estimated

to reduce a nations economic advancement by at

least 8% (direct productivity losses, losses via poorer

cognition, and losses via reduced schooling).9,10

Although preventable child mortality continues to

decrease, undernutrition is responsible or 45% o

deaths o children younger than 5 years, amounting

to more than 3 million deaths each year.8 Deciencies

o essential vitamins and minerals are widespread and

have important adverse eects on child survival and

development. Additionally, overweight in adults and

increasingly in children constitutes an emerging burdenthat is quickly establishing itsel globally, aecting both

poor and rich populations.8

Evidence presented in the accompanying Series on

Maternal and Child Nutrition8,1012 shows the importance

o adolescent and maternal nutrition or the health

o the mother and or ensuring healthy etal growth

and development. Fetal growth restriction is a cause

o 800 000 deaths in the rst month o lie each year,

more than a quarter o all neonatal deaths. 8 Newborn

babies with etal growth restriction have a substantially

increased risk o developing stunting by 24 months

o age. Furthermore, these adverse nutritional insultsearly in lie, when coupled with rapid weight gain later

in childhood, are important determinants o obesity

and non-communicable diseases in adulthood. Thus,

it is imperative to act as early as possible in the crucial

window o opportunity o pregnancy and the rst

2 years o lie.8 The emerging platorms or adolescent

health and nutrition might oer opportunities or

enhanced benets.10

According to our conservative estimates, we identiy

a set o ten proven nutrition-specic interventions,

which i scaled up rom present population coverage

to cover 90% o the need, would eliminate about900 000 deaths o children younger than 5 years in

the 34 high nutrition-burden countrieswhere 90%

o the worlds stunted children liveand reduce the

prevalence o stunting by a th, reducing the number

o children with stunted growth and development

by 33 million.10 The interventions with the largest

predicted eects on child mortality are treatment

o severe acute malnutrition throughout childhood;

promotion o inant and young child eeding, including

breasteeding and appropriate complementary oods;

and zinc supplementation. It is, however, important thatinterventions that have so ar contributed to reductions

in child mortality, such as vitamin A supplementation,

be continued where the need still exists. The cost o

scaling up this set o needed nutrition interventions to

90% coverage is estimated at Int$96 billion per year.10

Additionally, nutrition-sensitive activities should be

pursued in sectors that address the underlying deter-

minants o nutrition. Some, but not all, programmes

in agriculture, cash transers, early child development,

and schooling have been shown to improve nutrition

and broader developmental outcomes or children.11

The studies with the most positive eects had strongdesigns (including nutrition goals and actions), reached

mothers and children early (and or longer durations),

and targeted the poorest and most undernourished

groups. Many also included actions to empower women

and enhance their social status. More evidence is needed

rom programmes that have good designs, strong

implementation, and rigorous evaluation.

An enabling environment or nutrition requires

empirically sound, timely data about the nature o

the problem, evidence or what works and how, good

coherence between sectors, good coordination between

national and subnational levels, sufcient capacity tobuild commitment, implementation o programmes

at scale, and sustainable public and private means to

nance interventions.12

Countries that have managed to improve nutritional

status in these contexts have adopted an approach that

targets the whole o society.13 This approach requires a

good understanding o the political economy o nutri-

tion. Governments and other stakeholders in success-

ul countries have built alliances, managed tensions,

identied win-win outcomes, established strong

Panel: Global nutrition targets for 2025, endorsed by the

World Health Assembly

40% reduction o the global number o children

younger than 5 years who are stunted

50% reduction o anaemia in women o

reproductive age

30% reduction o low birthweight

No increase in childhood overweight

Increase the rate o exclusive breasteeding in the

rst 6 months to at least 50%

Reduce and maintain childhood wasting to less than 5%


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4 www.thelancet.com

accountability mechanisms, and innovated in themobilisation o resources or nutrition.11

The private sector is an important orce in shaping

nutrition outcomes and has the potential to do more.

Much more needs to be known about how dierent

orms o public policy, regulation, and nancial incen-

tives can support private organisations to do the right

things to improve nutrition. Knowledge in this area is

scarce and must be expanded rapidly.

The impetus or improving nutrition is stronger today

than 5 years ago. The World Health Assembly nutrition

targets14 or reduction o stunting, wasting, low birth-

weight, anaemia, and overweight, and increasing exclu-sive breasteeding in the rst 6 months o lie (panel),

can be achieved by 2025 with sufcient support. The

costs o inaction are enormous. As economies grow

and the rate o population growth slows, the returns

to improved cognitive perormance and psychological

unctioning in the workorce will expand substantially.

Benets will be greater where strategies integrate the

promotion o nutrition and child development.15

The new evidence provided in the Maternal and Child

Nutrition Series strengthens the case or a continued

ocus on the rst 1000 days. Investments within this

window can help meet crucial goals: the prevention oundernutrition, overweight, and poor child development

outcomes with longlasting eects on human capital

ormation. Because many women do not access

nutrition-promoting services until month 5 or 6 o

pregnancy, we draw attention to the need to ensure

women enter pregnancy in a state o optimum nutrition.

Nutrition is oundational to both individual and

national development. The post-Millennium Develop-

ment Goals agenda must put the resolution o all orms

o malnutrition at the top o its aims. An increase

in donor spending is crucial i nutrition targets are

to be met or surpassed. Government spending inLMICs needs to match or exceed this rate o increase.

Nutrition budget lines need to be established in all

high-burden countries. Governments need to be

supported to raise public resources or nutrition.

The increased mobilisation o private resources rom

individuals, businesses, and new philanthropies needs

to be incentivised towards the most eective ways o

improving nutrition. Scaling Up Nutrition is a crucial

driver o these needed actions and support or it must

remain strong.

Many nutrition gains have been made, but they needto be protected in the ace o new stressors such as

climate change, humanitarian crises, and ood price

volatility. We need to encourage innovation in design

and delivery o nutrition-specic interventions, to make

them even more aordable at scale. New incentives need

to be established that support innovations in nutrition-

sensitive programme design and implementationto

unleash their potential to achieve their own goals by

providing crucial additional support to eorts to reduce

malnutrition. This Series strengthens the evidence that

good nutrition is a undamental driver o a wide range

o development goals.Investments need to be directed not only to inter-

ventions, but also to the creation o environments

that enable them. This approach requires strategic

investment in commitment building, capacity, and

leadership; timely data describing the nature o the

malnutrition problem and its causes; evidence or

what works; accountability mechanisms; resource

mobilisation; and building o institutions required

or sustainable implementation. A political economy

approach to prioritisation o such investments is crucial

i viable enabling environments are to be created.

More research is needed to develop scalable inter-ventions or improve the eectiveness o existing ones

to have greater eects, especially by preventing etal

growth restriction and growth altering in inancy.

Although promising service delivery platorms exist in

communities, evidence is needed about how to ensure

that nutrition interventions reach the populations

with greatest need. More research is needed into the

barriers to eective implementation and into the costs

and logistics o scaling up: into the crucial elements o

capacity at dierent levels, into the development and

assessment o nancing mechanisms or nutrition,

and into ways to reduce the costs o implementation.Rigorous evidence is needed to show how the private

sector can best support optimum nutrition. Research is

also needed into the drivers o country success, how to

create enabling environments, and into the eatures o

nutrition-sensitive programmes that improve nutrition.

This year, 2013, represents the best opportunity yet

to make these proposed actions a reality. National and

international momentum to address human nutrition

and related ood security and health needs is at a high

level. Nutrition is now more prominent on the agendas


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www.thelancet.com 5

o the UN, G8, and G20, and supporting civil society,business, and academic organisations. We must work

together to seize this opportunity.

Maternal and Child Nutrition Study GroupGroup members: *Robert E Black (Johns Hopkins Bloomberg School

o Public Health, USA), Harold Alderman (International Food Policy

Research Institute, USA), Zulqar A Bhutta (Aga Khan University,

Pakistan), Stuart Gillespie (International Food Policy Research

Institute, USA), Lawrence Haddad (Institute o Development

Studies, UK), Susan Horton (University o Waterloo, Canada),

Anna Lartey (University o Ghana, Ghana), Venkatesh Mannar

(The Micronutrient Initiative, Canada), Marie Ruel (International

Food Policy Research Institute, USA), Cesar G Victora (Universidade

Federal de Pelotas, Brazil), Susan P Walker (The University o the

West Indies, Jamaica), Patrick Webb (Tuts University, USA)

[email protected]

REB serves on the Boards o the Micronutrient Initiative, Vitamin Angels, the

Child Health and Nutrition Research Initiative, and the NestlCreating Shared

Value Advisory Committee. VM serves on the Nestl Creating Shared Value

Advisory Committee. HA, ZAB, SG, LH, SH, AL, MR, CGV, SPW, and PW declare

that they have no conicts o interest.

1 Black RE, Allen LH, Bhutta ZA, et al, or the Maternal and ChildUndernutrition Study Group. Maternal and child undernutrition: globaland regional exposures and health consequences. Lancet 2008;371: 24360.

2 Bhutta ZA, Ahmed T, Black RE, et al, or the Maternal and ChildUndernutrition Study Group. What works? Interventions or maternal andchild undernutrition and survival. Lancet 2008; 371: 41740.

3 Victora CG, Adair L, Fall C, et al, or the Maternal and Child UndernutritionStudy Group. Maternal and child undernutrition: consequences or adulthealth and human capital. Lancet 2008; 371: 34057.

Delivery platforms for sustained nutrition in Ethiopia

The 2013 Lancet Series on Maternal and Child

Nutrition emphasises the crucial importance o

scale-up o eective nutrition interventions through

health and community delivery platorms. The Series

acknowledges that strong health systems are central to

achievement o this goal, and or progress towards the

2015 Millennium Development Goals (MDGs).1 A broad

consensus exists about the need or strengtheningo health systems to meet the goals o the health-

related MDGs by 2015.1 Because disease-control

programmes and general health services oten

share common service-delivery platorms, they are

necessary and complementary in countries with

a high disease burden, especially in sub-Saharan

Arica.2,3 Some ndings have suggested that health and

nutrition programmes can strengthen health systems

and, similarly, that health systems can strengthen

programme implementation.47 Furthermore, or such

strengthening to take place, a system or platorm or

service delivery should be country led and owned to

ensure sustainability and eectiveness.

Published Online

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4 Bryce J, Coitinho D, Darnton-Hill I, et al, or the Maternal and ChildUndernutrition Study Group. Maternal and child undernutrition: eectiveaction at national level. Lancet 2008; 371: 51026.

5 Morris SS, Cogill B, Uauy R. Eective international action againstundernutrition: why has it proven so difcult and what can be done toaccelerate progress? Lancet 2008; 371: 60821.

6 Scaling Up Nutrition. A ramework or action. 2010. http://unscn.org/les/Activities/SUN/PolicyBrieNutritionScalingUpApril.pd (accessed April 2,2013).

7 Bezanson K, Isenman P. Scaling up nutrition: a ramework or action.Food Nutr Bull 2010; 31: 17886.

8 Black RE, Victora CG, Walker SP, et al, and the Maternal and Child NutritionStudy Group. Maternal and child undernutrition and overweight inlow-income and middle-income countries. Lancet 2013; published online


9 Horton S, Steckel RH. Global economic losses attributable to malnutrition19902000 and projections to 2050. In: Lombard B, ed. How much haveglobal problems cost the world? A scorecard rom 1900 to 2050.Cambridge: Cambridge University Press, 2013 (in press).



12 Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N, and the Maternal andChild Nutrition Study Group. The politics o reducing malnutrition:building commitment and accelerating progress. Lancet 2013; publishedonline June 6. http://dx.doi.org/10.1016/S0140-6736(13)60842-9.

13 Dube L, Pingali P, Webb P. Paths o convergence or agriculture, health, andwealth. Proc Natl Acad Sci USA 2012; 109: 12294301.

14 WHO. Discussion paper. Proposed global targets or maternal, inant andyoung child nutrition. Geneva: World Health Organization, 2012.

15 Grantham-McGregor S, Cheung YB, Cueto S, et al. Developmental potential inthe rst 5 years or children in developing countries. Lancet 2007; 369: 6070.

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In the past ew years, many countries have workedto develop systems and inrastructure at the most

decentralised level o services, and these investments

have enabled populations to access essential services

in sectors such as health, agriculture, education, and

social welare. Ethiopia is exemplary in this regard in

view o the countrys progress towards some o the

key MDGs, which is mainly attributable to a decentral-

ised service delivery platormthe Health Extension

Programme.8 Launched in 2003, this programme was

organised to provide uni versal access to primary health

care, mainly preventive services,6,7 through more than

38 000 government-salaried emale health extensionworkers. Two workers were placed in a health post

to serve each kebele (the smallest administrative

unit) o about 5000 people nationwide. Through

this programme new vaccines were introduced and

health services expanded, which improved health

and nutrition care practices, and investments were

made in education and social economic development,

contributing to a reduction in the number o child

deaths by nearly hal.9,10

The present estimate (supported by the Central

Statistical Agency) or the mortality rate in children

younger than 5 years in Ethopia is 77 per 1000 livebirths(compared with 166 in 2000 and 123 in 2005).11 On the

basis o the present trend, Ethiopia is predicted to meet

MDG 4, to reduce child mortality, by 2015, by having

a mortality rate in children younger than 5 years o

68 per 1000 livebirths.12 Furthermore, a comparison o

national levels o malnutrition in the 2000 and 2011

Ethiopia Demographic and Health Surveys (EDHS)

shows that stunting has declined rom 58% to 44%,

underweight rom 41% to 29%, and prevalence o

wasting rom 12% to 10%.10 Globally, the prevalence o

stunting in children younger than 5 years has allen by

36% in the past two decades, rom an estimated 40%in 1990, to 26% in 2011.9

To consolidate the gains and enhance the eectiveness

o the Health Extension Programme, the Government

o Ethiopia has designed a scaling-up strategy, in the

orm o a so-called health development army, which will

scale up documented best practices and use amilies as

role models. Such a strategy is based on social learning

theory whereby peer-to-peer modelling can dissemin-

ate emerging inormation and instil improved health-

seeking behaviours at community level.

The Health Extension Programme plays a crucial partin the success o the national nutrition programme and

strategy that was introduced in Ethiopia in 2008. The

community-based management o acute malnutrition

approach o the Health Extension Programme manages

more than 300 000 children in more than 10 000 health

posts annually, has provided vitamin A supplementation

and deworming tablets to 11 million children and

700 000 pregnant and lactating women every 6 months

since 200506, and distributes iron-olate supplemen-

tation targeted to reach 80% o pregnant women every

year.13 Interventions o the community-based nutrition

programme include inant and young child nutrition,and growth monitoring and promotion via the Triple A

cycle (assess the problem, analyse its causes and possible

solutions, and take appropriate action). The community-

based nutrition programme is currently being supported

in more than 300 ood-insecure woredas (districts),

reaching 1 500 185 (80%) children younger than 2 years.

Eorts o the community-based nutrition programme

have resulted in more than 50% o children in Ethiopia

being exclusively breasted (EDHS, 2011).10 However, the

proportion o children receiving a minimum acceptable

diet is only 4% in Ethiopia, show ing the urgent need to

nalise a national strategy or improvement o quantityand quality o complementary eeding.

The revised national nutrition programme spanning

201315 will address these challenges by emphasising

the rst 1000 days o lie, with a ocus on children

younger than 2 years, pregnant and lactating women,

and adolescent girls, to break the intergenerational

cycle o malnutrition. Furthermore, the revised pro-

gramme will emphasise actions or acceleration o

stunting reduction by ocusing on nutrition-sensitive

interventions in other development sectors such as

education, agriculture, social protection and womens

aairs, and civil society organisations and the privatesector. The role o health extension workers and the

health development army will continue to be central

to achievement o equitable access o all vulnerable

women and children to both curative and preventive

services, and to ensure that targets specied in the

health sector development plan IV o Ethiopia are met.13

Ethiopias actions have enabled development workers

to engage people at risk in an integrated manner

using a unied Health Extension Programme, enabling

achievement o great gains in child survival and


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nutrition. The Government o Ethiopia, on the basis oexperiences in the past 10 years o this programme and

the substantial improvements in nutritional status,

believes that even greater eorts can be made to reduce

stunting. The government will continue to optimise the

revised national nutrition programme and the global

eorts on nutrition such as Scaling Up Nutrition (SUN)

and Renewed Eorts Against Child Hunger (REACH),14

which are mechanisms to catalyse urther multisectoral

nutrition-sensitive actions beyond the health sector.

Nutrition, as one o many crucial indicators o health

status, should be used or close programmatic link-

ages and synergies between targeted social protectioninterventions. These synergistic actions across social

services will contribute towards increased resource

allocation or the national nutrition programme, and

ensure that sustainable interventions are scaled up to

improve ood and nutrition security.

*Ferew Lemma, Joan MatjiEthiopian Federal Ministry o Health, PO Box 1234, Addis Ababa,

Ethiopia (FL); and UNICEF Ethiopia, Addis Ababa, Ethiopia (JM)

[email protected]

We declare that we have no conicts o interest.

1 Singh A. Strengthening health systems to meet MDGs. Health Policy Plan

2006; 21: 32628.

Only collective action will end undernutrition

We are in a race against time to eradicate the global

scourge o undernutrition. Undernutrition cripples global

economic growth and development, and uture global

prosperity and security are intimately linked with our

ability to respond adequately to this urgent challenge.

The new Series in The Lancet shows that undernutrition

contributes to the deaths o about 3 million children

each year45% o the total.1 Its results stunt the physicalgrowth and lie chances o millions o people, and or

Arica and Asia estimates suggest that up to 11% o

national economic productivity is lost to undernutrition.2

The evidence provided in this Series should act as a

turning point to galvanise global action. The solution

lies largely in the early years o lie, when the oundations

or human potential are laidgetting the right nutrients

at the right time prevents undernutrition. The result is

heightened educational attainment, adult wages, and

economic productivity.

Women and girls are at the heart o this message.

As the bearers and carers o children, their health and

economic potential is entwined with that o uture

Published Online

June 6, 2013


S0140-6736(13)61084-3

2 WHO. Everybodys business. Strengthening health systems to improvehealth outcomes: WHOs ramework or action. Geneva: World HealthOrganization, 2007.

3 WHO. The Global Fund strategic approach to health systems strengthening:report rom WHO to the Global Fund Secretariat. Geneva: World HealthOrganization, 2007.

4 Atun R, Bennett S, Duran A. When do vertical (stand-alone) programmeshave a place in health systems? Copenhagen: World Health OrganizationRegional Ofce or Europe and the European Observatory on HealthSystems and Policies, 2008.

5 Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O. A systematic review o theevidence on integration o targeted health interventions into healthsystems. Health Policy Plan 2010; 25: 114.

6 Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O. Integration o targeted healthinterventions into health systems: a conceptual ramework or analysis.Health Policy Plan 2010; 25: 10411.

7 Atun R, Menabde N. Health systems and systems thinking: In: Coker R,Atun R, McKee M, eds. Health systems and the challenge o communicablediseases: experiences rom Europe and Latin America. Berkshire, UK: Open

University Press, 2009: 12140.8 Wakabi W. Extension workers drive Ethiopias primary health. Lancet 2008;

372: 880.

9 UN Childrens Fund. Improving child nutrition: the achievable imperativeor global progress. New York: UNICEF, 2013.

10 Central Statistical Agency, ICF International. Ethiopia Demographic andHealth Survey 2011. March, 2012. http://measuredhs.com/pubs/pd/FR255/FR255.pd (accessed May 22, 2013).

11 WHO. Ethiopia: health prole. May, 2013. http://www.who.int/gho/countries/eth.pd (accessed May 22, 2013).

12 Ministry o Finance and Economic Development, UN Ethiopia. Child survival,health and nutrition. In: Nebede A, Pearson R, eds. Investing in boys and girlsin Ethiopia: past, present and uture, 2012. Ethiopia: UNICEF, 2012: 3553.

13 Federal Democratic Republic o Ethiopia, Ministry o Health. Health SectorDevelopment Program IV, 2010/112014/15. Addis Ababa: FederalDemocratic Republic o Ethiopia Ministry o Health, 2010.

14 REACH Partnership. Annual report 2012. 2012. http://www.reachpartnership.org/documents/312104/315126/REACH+Annual+Report+

2012?version=1.0 (accessed May 22, 2013).

For more on the SUN initiative

see http://scalingupnutrition.

org/resources-archive

Corbis


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generations. Unless girls grow well in early childhoodand adolescence and enter into motherhood well

nourished, are lent support during pregnancy,

protected rom heavy physical labour, and empowered

to breasteed and provide good ood or their

babies and toddlers, the intergenerational cycle o

undernutrition will not be broken. This Series shows

that poor maternal nutrition at conception and during

pregnancy is a major contributor to undernutrition in

childhood.1 Empowering women to make the right

choices or their health, and that o their children, is

crucial to solving this challenge.

Why is this such an urgent issue? Important demo-graphic changes are occurring in many countries with

high levels o undernutrition. The ratio o the work-

ing age to non-working age population is rising and

will peak in the next 20 years, and this increase in

the available workorce has substantially boosted

economic growth in many parts o the world.3 Any

such demographic dividend will be even greater in well-

nourished populations. Additionally, rapid urbanisation,

increased sedentary behaviour, and a transition in

dietary patterns has resulted in a ast rise o obesity in

middle-income and even low-income countries. This

Series emphasises that undernourished children are atincreased risk o becoming overweight and developing

non-communicable diseases such as diabetes in later

lie.1 Acting now brings a triple benet: it saves lives

today, maximises economic opportunity, and helps to

reduce obesity and chronic disease in the uture.

This Series shows that there are simple and

proven interventions that can substantially reduce

undernutrition and mortality in children. Many o

these interventions deliver an excellent return on

investment and should be delivered at scale without

delay. However, making a lasting eect on the root

causes o undernutrition will need more eort. Brazilsremarkable experience during the past 20 years shows

us that the right programmes need to be matched with

strong political leadership and determination. Brazils

success resulted rom a whole-government response,

a clear ocus on groups at greatest risk, strong civil

society engagement, and investments to track progress

and use data to strengthen accountability and inorm

policy choices.4

In addition to strong national action on under-

nutrition, we need to take a hard look at our global

agriculture and ood system. As the global populationrises, our ood system needs to keep pace with the

demand or both dietary energy and the essential

vitamins and minerals needed or human health. Our

agriculture and ood system needs to be protable or

armers and the wider ood sector, environmentally

sustainable, and directly supportive o the health and

nutritional needs o populations.

Everyone is part o the solution. Governments

need to lead; businesses need to identiy how to

improve nutrition through their business models

and employment practice; civil society organisations

need to help citizens to drive transparency andaccountability; and the scientic community needs to

keep us ocused on evidence about what works. Policy

commitments, capacity strengthening, and targeted

nancing are all essential.

Global eorts on ood and nutrition will likewise

be substantially boosted by a clear signal o nutrition

priorities in the post-2015 development agenda. This

agenda will do more than steer aid; it should provide

direction on global investment, buy in support rom the

private sector, and encourage a coherent approach rom

international institutions. Nutrition should be centrally

positioned in that agenda to ensure energy and nutrientneeds are met at each stage o lie.

The rst Lancet Series on maternal and child under-

nutrition, published in 2008, helped to start the race

to eradicate poor nutrition. In the past 5 years the

governments o 35 countries have committed to do

more to tackle undernutrition, and have joined the

Scaling Up Nutrition movement. On the last day o the

2012 Olympics, the governments o the UK and Brazil

co-hosted an event in London, UK, to generate political

momentum in the ght against undernutrition. On

June 8, 2013, the Nutrition or Growth high level event

in London will help to secure a global response thatwill include nancial, business, scientic, and political

commitments matched to the scale o the challenge.

Progress will be reviewed annually and again at the

Olympics in Rio de Janeiro, Brazil, in 2016. We cannot

aord to miss this opportunity to act together to

beat undernutrition.

*Anna Taylor, Alan D Dangour, K Srinath ReddyUK Department or International Development, London

SW1A 2EG, UK (AT, ADD); Faculty o Epidemiology and Population

For Scaling Up Nutrition see

http://scalingupnutrition.org

For the frst LancetSeries on

maternal and child

undernutrition see http://www.

thelancet.com/series/maternal-

and-child-undernutrition


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www.thelancet.com 9

Nutrition-sensitive food systems: from rhetoric to action

Action to improve the nutrition sensitivity o oodsystemsand thereby increase the nutritional value o

ood or people around the worldoers substantial

but underused opportunities.1,2 The rhetoric about such

opportunities brought about by the global ood crisis

in 200708 has not resulted in much new action, or

at least two reasons. First, goals other than improved

nutrition are pursued by strong economic and political

interests in both the agricultural sector and the post-

harvest value chain.3 Farmers and other economic

agents in ood systems aim to make money subject

to reasonable levels o risk, and governments pursue

policies that are compatible with the interests opolitically powerul stakeholder groups.4 Malnourished

populations are rarely among these interests.

The very high value o improved nutrition to

societies should be supported by alignments to create

compatibility between nutrition and economic goals

or armers and processors, and political momentum3

has to be created to oster policy interventions that

make ood systems nutrition sensitive. Governments

could pursue two kinds o policy action: they could

either change the behaviour o armers, consumers,

ood processors, and other economic agents in the

system through incentives, regulations, and knowledge;or they could accept present behaviours and introduce

health-specic and nutrition-specic interventions

to compensate or any nutritional damage done

or improvements orgone. Although changing o

behaviour is likely to be more cost-eective and

sustainable, the second option is the most common. For

example, ood-system policies and the private sector

promote inexpensive calories and expensive nutrients,

resulting in overweight and micronutrient deciencies.

Health and nutrition-specic interventions, such

as treatment o chronic diseases and micronutrientsupplementation, are introduced to remedy problems

that could have been avoided.

The appropriate policy interventions to change

behaviour will be context specic and might include

agricultural research to increase productivity o ruit

and vegetable cultivation and reduce micronutrient

deciency; taxes on sugar, sweeteners, and at to reduce

the prevalence o obesity; regulations or advertising

and promotion; and education about nutrition.5 In high-

income and rapidly growing low-income countries, the

agricultural sector has become or is rapidly becoming

a supplier o raw materials or the ood processingindustry, rather than a provider o ood or direct

consumption. As this transition proceeds, the potential

or improvements to nutrition through nutrition-

sensitive ood systems moves rom agriculture to the

post-harvest value chain. The transition amplies health

and nutrition risks by promotion o what Monteiro

Published OnlineJune 6, 2013


S0140-6736(13)61053-3

BloombergviaGettyImages

Health and Leverhulme Centre or Integrative Research inAgriculture and Health, London School o Hygiene & Tropical

Medicine, London, UK (ADD); and Public Health Foundation o

India, New Delhi, India (KSR)

[email protected]

We declare that we have no conicts o interest.



2 Horton S, Steckel RH. Malnutrition: Global economic losses attributable tomalnutrition 19002000 and projections to 2050. In: Lomborg B, ed.How much have global problems cost the world? A scorecard rom 1900 to2050. Cambridge: Cambridge University Press, 2013 (in press).

3 Eastwood R, Lipton M. Demographic transition in sub-Saharan Arica:how big will the economic dividend be? Popul Stud (Camb) 2011; 65: 935.

4 Monteiro CA, Benicio MH, Conde WL, et al. Narrowing socioeconomicinequality in child stunting: the Brazilian experience, 19742007.Bull World Health Organ 2010; 88: 30511.


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10 www.thelancet.com

and colleagues call ultra-processed oods,6,7

resultingin unhealthy dietary patterns. However, policy action

to regulate and incentivise the ood industry to avoid

such negative health and nutrition eects and change

consumer preerences is very scarce.

A second reason or lack o action to improve nutrition

is the xation o the health and nutrition community

on randomised controlled trials (RCTs) as the only

legitimate source o evidence.8,9 Unortunately, RCTs

the gold standard in health researchare generally

impossible to apply to the ood system except in small,

usually unimportant, projects. Health and nutrition

eects resulting rom agricultural and other ood-system policies and programmes are very difcult to

assess with RCTs, partly because treatments cannot be

randomised and because the eect pathway is long. Yet

the most promising opportunities or improvement

o health and nutrition are undoubtedly ound in such

policies, and not in home gardens and other minor

projects which are amenable to study within the

ramework o randomised trials.

Although existing evidence obtained by other

approaches is deemed inconclusive1 and does not

support policy intervention, the pathways through

which ood systems can aect nutrition (positivelyor negatively) are well known. Furthermore, key

components making up these pathways, such as

incomes, prices, womens time allocation, dietary

diversity, advertising and promotion, and household

and individual behaviour have a substantial eect

on nutrition. Thus, i pathway analysis shows that

changes in the ood system improve one or more o

these componentseg, dietary diversity or womens

time allocationand such improvements reduce micro-

nutrient deciencies, is such evidence really acceptable

or policy guidance only i it is derived rom RCTs? I

so, the evidence will be limited to small ood-systems

In April, 2010, a policy brieScaling Up Nutrition:

A Framework or Actionwas released at the spring

meetings o the World Bank and International

Monetary Fund. It was a collective eort stimulated

by the publication in January, 2008, o The Lancets

Series on undernutrition. The Lancet Series encouraged

an emphasis on the 1000 day window rom the

start o pregnancy to a childs second birthday, with

interventions that are both cost-eective and yield

high returns or cognitive development, individual

adult earnings, and economic growth. A second Series

on nutrition, published in The Lancet,14 now explicitly

Global child and maternal nutritionthe SUN rises

Published Online

June 6, 2012


S0140-6736(13)61086-7

For the Scaling Up Nutrition

policy briesee http://

scalingupnutrition.org/

wp-content/uploads/pdf/

SUN_Framework.pdf

programmes such as kitchen garden projects, whereasthe really important changes or nutrition, such as

prioritisation o agricultural research to enhance pro-

ductivity in ruit and vegetable cultivation so as to

reduce prices and improve micronutrient status, and

various policies to change womens time allocation or

prices o various oods, will be ignored because they

cannot be studied in RCTs.1,10

Per Pinstrup-AndersenDivision o Nutritional Sciences, Cornell University, Ithaca,

NY 14853, USA

[email protected]

I declare that I have no conicts o interest.


2 Pinstrup-Andersen P. Food systems and human health and nutrition:an economic policy perspective with a ocus on Arica. Oct 11, 2012. http://iis-db.stanord.edu/evnts/6697/Pinstrup-Andersen_10_11_12.pd(accessed May 2, 2013).

3 Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N, and the Maternal andChild Nutrition Study Group. The politics o reducing malnutrition: buildingcommitment and accelerating progress. Lancet 2013; published online

June 6. http://dx.doi.org/10.1016/S0140-6736(13)60842-9.

4 Pinstrup-Andersen P, Watson DD II. Food policy or developing countries:the role o government in global, national, and local ood systems. Ithaca,NY: Cornell University Press, 2011.

5 Herorth A, Jones A, Pinstrup-Andersen P. Prioritizing nutrition inagriculture and rural development: guiding principles or operationalinvestments. Washington, DC: World Bank, 2012.

6 Monteiro CA, Levy RB, Claro RM, deCastro IRR, Cannon G. Increasingconsumption o ultra-processed oods and likely impact on human health:evidence rom Brazil. Public Health Nutr2011; 14: 513.

7 Monteiro CA. Nutrition and health. The issue is not ood, nor nutrients, somuch as processing. Public Health Nutr2009; 12: 72931.



10 Masset E, Haddad L, Cornelius A, Isaza-Castro J. A systematic review oagricultural interventions that aim to improve nutritional status ochildren. London: EPPI-Centre, Social Science Research Unit, Institute o

Education, University o London, 2011.


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www.thelancet.com 11

shows that the solution to malnutrition relies on acollective eort in which all stakeholdersgovernments,

academia, civil society, UN system organisations,

oundations, development banks, and businessescarry

out specic roles in ensuring that interventions are

delivered equitably and at scale.

The policy brie, which quickly became known as the

SUN Framework, set the stage or the transormation

that is now happening in global nutrition. It called or

country-owned nutrition strategies and programmes;

urgent scaling up o evidence-based and cost-eective

interventions; integration o nutrition within national

strategies or gender equality, agriculture, ood security,social protection, education, water supply, sanitation,

and health care; and a substantial increase in domestic

support and external assistance or nutrition within the

ood security, social protection, and health sectors. The

SUN Road Map, prepared later in 2010 and revised in

2012, set out ways or a wide range o groups to work

together in sharpening, scaling up, and aligning their

responses to peoples nutritional needsand achieving

results.

Alongside the 1000 days advocacy partnership,

the SUN Movement was launched at the UN General

Assembly in September, 2010. It takes orward the SUNRoad Map by encouraging coherence and eectiveness

among all groups working or better nutrition; it is not

an initiative, project, or programme. By April, 2013,

35 countries had joined the SUN Movement with

commitments that are in line with the SUN Framework

and Road Map. These countries nutrition solutions

show the commitments o political leaders, whole-o-

society responses, careul tracking o progress, and the

benets o shared experience.

The second Lancet nutrition Series provides a range

o valuable insights as the SUN Movement moves

through 2013, a year dense with events that willmove nutrition to the heart o the development

agenda. It calls or a substantial increase o political

commitment in responding to the complex causes o

undernutrition. It recognises that the SUN Movement

has the potential to harness such change and yield

durable results.

The rst paper1 o the Series leaves no doubt as to

why nutrition is key or sustainable development

and the wellbeing o entire populations. The second

paper2 strengthens the arguments o the 2008 Lancet

Series by bringing additional evidence to support the

ocus on ensuring that all women, girls, and young

children are able to access specic interventions o

good quality; they should be included in mainstream

eorts or public health, amily planning, and water

and sanitation. The third paper3 sets the oundation

or evidence-based research into achieving outcomes

through nutrition-sensitive strategies in our keyareas: agriculture and ood, social security, early child

development, and classroom education. It draws on

the experience o countries that have made great

progress when stressing that gender and social

equality are the cornerstones o nutritional success.

By ocusing on the political context or eective

action, the ourth paper4 recalls that the realisation o

human rights, a commitment to equity, and gender

equality should be properly prioritised. It includes

important proposals or ways in which business can

best be engaged (and the challenges o doing so), and

encourages increased involvement o civil society at alllevels. It likewise underlines the need or governments

to increase their own accountability or ensuring

that people are able to achieve good nutrition and

to ensure the existence o a air and transparent

ramework or regulating any entity that mighteven

unwittinglyundermine nutritional justice.

At the May, 2012, World Health Assembly,

government representatives agreed ambitious

goals or reduction o all orms o malnutrition,

including obesity. This Lancet Series points out that

BloombergviaGet

tyImages

For the Lancets 2008 Series

on maternal and child

undernutrition see http://www.

thelancet.com/series/maternal-

and-child-undernutrition

For the SUN Movement Revised

Roadmap see http://

scalingupnutrition.org/wp-

content/uploads/2012/10/SUN-

Movement-Road-Map-

Septemeber-2012_en.pdf

For the 1000 days partnership

see http://www.thousanddays.

org


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these goals can only be achieved through improved

nutrition governance, more human resources, better

demonstration o results, and increased investments

rom domestic and international sources. In the past

3 years the SUN Movement has provided a platorm

to enable leaders to pledge to intensiy eorts or

improved nutrition. 2013 provides a once-in-a-lietime

opportunity to strengthen worldwide resolve or

improved nutrition, through commitments being made

in a series o international and regional events.

The publication o the second Lancet Series is

timely and reinorces the urgency or transormationo political commitment into actions that lead to

improvements in nutrition. The Series brings scientic

rigour to the challenge o equitable delivery o eective

services at scaleboth now and in the years to come.

The association between nutrition in early lie and

long-term health has been o interest or decades.

Since the articulation o the etal origins hypothesis by

David Barker and colleagues,1 there has been debateabout the implications o etal undernutrition and

early childhood growth on outcomes o importance

in adult health and risks o chronic diseases. Both

epidemiological and animal studies have shown that

the risk o metabolic syndrome is signicantly increased

ater exposure to suboptimum nutrition during crucial

periods o development.1 The importance o these

ndings greatly increased ater reports about the global

burden o non-communicable diseases and risk actorswere published in December, 2012.2

Evidence or the importance o early nutrition or

adult outcomes was derived initially rom obser-

vational cohort studies3 and was reafrmed by analysis

o outcome data rom several cohort studies in

2008.4 This analysis4 was ocused on a meta-analysis

o coefcients rom dierent sites: birthweight,

weight and length Z scores, and stunting at age

2 years. In The Lancet, Linda Adair and colleagues5

report ndings rom a study in which they pooled

data rom ve birth cohorts and investigated how

linear growth and relative weight gain in several ageranges aected adult outcomes. They report that

higher birthweight was associated with an adult body-

mass index o greater than 25 kg/m (odds ratio 128,

95% CI 121135) and a reduced likelihood o short

stature (049, 044054) and o not completing

secondary school (082, 078087). Faster linear

growth was also strongly associated with reduced

likelihood o short adult stature (age 2 years: 023,

020052; mid-childhood 039, 036043) and o

not completing secondary school (age 2 years: 074,AndrewAitchison/InPictures/Corbis

Early nutrition and adult outcomes: pieces of the puzzle

Published Online

March 28, 2013


S0140-6736(13)60716-3

See Online/Articleshttp://dx.doi.org/10.1016/

S0140-6736(13)60103-8

David NabarroSUN Movement Secretariat, Villa La Pelouse (2nd Floor), Palais Des

Nations, 1201 Geneva, Switzerland

[email protected]


1 Black RE, Victora CG, Walker SP, et al, and the Maternal and Child NutritionStudy Group. Maternal and c hild undernutrition and overweight inlow-income and middle-income countries. Lancet 2013; published online




4 Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N, and the Maternal andChild Nutrition Study Group. The politics o reducing malnutrition:building commitment and accelerating progress. Lancet 2013; publishedonline June 6. http://dx.doi.org/10.1016/S0140-6736(13)60842-9.


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067078; mid-childhood 087, 083092). Fasterrelative weight gain was associated with an increased

risk o adult overweight (age 2 years: 151, 143160;

mid-childhood 176, 169191) and elevated blood

pressure (age 2 years: 107, 101113; mid-childhood:

122, 115130).

Notwithstanding the key ndings, several limitations

o this pooled analysis should be recognised. The

authors had to make do with disparate inormation

about socioeconomic status and income, and impute

some inormation that was missing. Although they

adjusted or maternal education and socioeconomic

status (largely assets rather than income), otherpotential conounding actors (eg, household and

learning environment) could not be assessed in relation

to attained schooling. Several additional limitations

preclude rm conclusions. Little or no inormation was

available about maternal nutrition and micronutrient

status. Additionally, Adair and colleagues do not

report any outcomes related to intrauterine growth

retardation or gestational age at birth, and merely

report association with birthweight, which might

be oversimplied. Being small or gestational age at

term, and especially preterm, has now been recognised

as a major risk actor or excess newborn and inantmortality6 and accounts or a substantial proportion

o child stunting.7 Prematurity is associated with

increased risks o metabolic syndromes in later lie.8

Potential variations in body composition o newborn

babies might not be captured by mere measurement o

birthweight or size. So-called thin-at inantsie, small

newborn babies that have elevated body at content

have been described9 and could be associated with

increased risks o insulin resistance in childhood.10

These limitations aside, Adair and colleagues nd-

ings5 are some o the most important rom existing

cohorts linking early childhood nutritionespeciallybirthweight and improved patterns o linear growth

with long-term outcomes. They have clear implications

or public health policy and nutrition interventions. As

shown by an analysis o evidence-based interventions, 11

a ocus on improvements in nutrition in pregnancy

and linear growth in the rst 2 years o lie could lead

to substantial reductions in stunting and improved

survival. These improvements orm the basis or the

emphasis on the rst 1000 days o lie, which has

been used eectively to scale up nutrition activities.12

However, this tenet could be too simplistic, becauseit ocuses on care during pregnancy and ignores the

vital contribution o maternal health and nutrition

in the periods beore and just ater conception to

intrauterine and postnatal growth. Evidence supports

an association between micronutrient supplemen-

tation around the time o conception and DNA

methylation13 and increased methylation o the IGF2

genes in childhood,14 indicating that these actors

could aect linear growth postnatally. Although

Adair and colleagues analysis o birth outcomes in

the international cohorts does not shed light on the

importance o maternal health and nutrition beoreconception, these actors might be just as important

as postnatal actors and should be investigated.

What is the way orward? Although the evidence

emerging rom observational studies such as Adair

and colleagues is important or policy, well designed

prospective studies with appropriate interventions and

ollow-up are clearly needed. The outcomes should

include elements o child development, education,

employment, and earnings, which would allow

improved estimation o eect on human capital.

Although expensive and difcult to organise and

implement, such cohort studies are a crucial investmentor the uture and, in view o the interest in human

development in the post-2015 era, should be prioritised

or unding.

Zulfqar A BhuttaDivision o Women and Child Health, Aga Khan University, Karachi

74800, Pakistan

[email protected]


1 Barker DJ. Sir Richard Doll lecture: developmental origins o chronic disease.Public Health 2012; 126: 18589.

2 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment o burdeno disease and injury attributable to 67 risk actors and risk actor clustersin 21 regions, 19902010: a systematic analysis or the Global Burden oDisease Study 2010. Lancet 2012; 380: 222460.

3 Barker DJP, Godrey KM, Gluckman PD, Harding JE, Owens JA, Robinson JS.Fetal nutrition and cardiovascular disease in adult lie. Lancet 1993;341: 93841.

4 Victora CG, Adair L, Fall C, et al, or the Maternal and Child UndernutritionStudy Group. Maternal and child undernutrition: consequences or adulthealth and human capital. Lancet 2008; 371: 34057.

5 Adair LS, Fall CHD, Osmond C, et al, or the COHORTS group. Associationso linear growth and relative weight gain during early lie with adult healthand human capital in countries o low and middle income: ndings romve birth cohort studies. Lancet 2013; published online March 28. http://dx.doi.org/10.1016/S0140-6736(13)60103-8.

6 Marchant T, Willey B, Katz J, et al. Neonatal mortality risk associated withpreterm birth in East Arica, adjusted by weight or gestational age:individual participant level meta-analysis. PLoS Med 2012; 9: e1001292.


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8 Parkinson JRC, Hyde M J, Gale C, Santhakumaran S, Modi N. Preterm birthand the metabolic syndrome in adult lie: a systematic review andmeta-analysis. Pediatrics 2013; published online March 18. DOI:10.1542/peds.2012-2177.

9 Yajnik CS, Fall CH, Coyaji KJ, et al. Neonatal anthropometry:the thin-at Indian babythe Pune Maternal Nutrition Study.Int J Obes Relat Metab Disord 2003; 27: 17380.

10 Lakshmi S, Metcal B, Joglekar C, Yajnik CS, Fall CH, Wilkin TJ. Dierences inbody composition and metabolic status between white UK and AsianIndian children (EarlyBird 24 and the Pune Maternal Nutrition Study).Pediatr Obes 2012; 7: 34754.


12 Save The Children. Nutrition in the rst 1000 days: state o the worldsmothers 2012. May, 2012. http://www.savethechildren.ca/document.doc?id=195 (accessed March 21, 2013).

13 Cooper WN, Khulan B, Owens S, et al. DNA methylation proling atimprinted loci ater periconceptional micronutrient supplementation inhumans: results o a pilot randomized controlled trial. FASEB J 2012;26: 178290.

14 Steegers-Theunissen RP, Obermann-Borst SA, Kremer D, et al.Periconceptional maternal olic acid use o 400 microg per day is related toincreased methylation o the IGF2 gene in the very young child. PLoS One2009; 4: e7845.


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Maternal and Child Nutrition 1

Maternal and child undernutrition and overweight in

low-income and middle-income countries

Robert E Black, Cesar G Victora, Susan P Walker, Zulfqar A Bhutta*, Parul Christian*, Mercedes de Onis*, Majid Ezzati*,

Sally Grantham-McGregor*, Joanne Katz*, Reynaldo Martorell*, Ricardo Uauy*, and the Maternal and Child Nutrition Study Group

Maternal and child malnutrition in low-income and middle-income countries encompasses both undernutrition anda growing problem with overweight and obesity. Low body-mass index, indicative o maternal undernutrition, hasdeclined somewhat in the past two decades but continues to be prevalent in Asia and Arica. Prevalence o maternaloverweight has had a steady increase since 1980 and exceeds that o underweight in all regions. Prevalence o stuntingo linear growth o children younger than 5 years has decreased during the past two decades, but is higher in south

Asia and sub-Saharan Arica than elsewhere and globally aected at least 165 million children in 2011; wastingaected at least 52 million children. Defciencies o vitamin A and zinc result in deaths; defciencies o iodine andiron, together with stunting, can contribute to children not reaching their developmental potential. Maternalundernutrition contributes to etal growth restriction, which increases the risk o neonatal deaths and, or survivors,o stunting by 2 years o age. Suboptimum breasteeding results in an increased risk or mortality in the frst 2 yearso lie. We estimate that undernutrition in the aggregateincluding etal growth restriction, stunting, wasting, anddefciencies o vitamin A and zinc along with suboptimum breasteedingis a cause o 31 million child deathsannually or 45% o all child deaths in 2011. Maternal overweight and obesity result in increased maternal morbidityand inant mortality. Childhood overweight is becoming an increasingly important contributor to adult obesity,diabetes, and non-communicable diseases. The high present and uture disease burden caused by malnutrition inwomen o reproductive age, pregnancy, and children in the frst 2 years o lie should lead to interventions ocused onthese groups.

Introduction

Maternal and child malnutrition, encompassing bothundernutrition and overweight, are global problems withimportant consequences or survival, incidence o acuteand chronic diseases, healthy development, and theeconomic productivity o individuals and societies.Maternal and child undernutrition, including stunting,wasting, and deciencies o essential vitamins andminerals, was the subject o a Series 15 in The Lancet in2008, which quantied their prevalence, short-term andlong-term consequences, and potential or reductionthrough high and equitable coverage o proven nutritioninterventions. The Series identied the need to ocus onthe crucial period o pregnancy and the rst 2 years oliethe 1000 days rom conception to a childs secondbirthday during which good nutrition and healthy growthhave lasting benets throughout lie. The 2008 Series alsocalled or greater national priority or nutrition pro-grammes, more integration with health programmes,enhanced intersectoral approaches, and more ocusand coordination in the global nutrition system o inter-national agencies, donors, academia, civil society, and theprivate sector. 5 years ater that series, we intend notonly to reassess the problems o maternal and childundernutrition, but also to examine the growing problemso overweight and obesity or women and children andtheir consequences in low-income and middle-incomecountries (LMICs). Many o these countries are said tosuer the so-called double burden o malnutrition, with

continuing stunting o growth and deciencies o essential

nutrients along with obesity in national populations andwithin amilies. We also want to assess national progressin nutrition programmes and international actions con-sistent with our previous recommendations.

Published Online

June 6, 2013


S0140-6736(13)60937-X

This is the frst in a Series o

our papers about maternal and

child nutrition

*Members listed alphabetically

Members listed at end o paper

Johns Hopkins University,

Bloomberg School of Public

Health, Baltimore, MD, USA

(Pro R E Black MD,

Pro P Christian DrPH,

Pro J Katz ScD);Universidade

Federal de Pelotas, Pelotas,

Rio Grande do Sol, Brazil

(Pro C G Victora MD);The

University of the West Indies,

Tropical Medicine Research

Institute, Mona Campus,

Kingston, Jamaica

(Pro S P Walker PhD);

The Aga Khan University andMedical Center, Department of

Pediatrics, Karachi, Pakistan

(Pro Z A Bhutta PhD);World

Key messages

Iron and calcium deciencies contribute substantially to maternal deaths

Maternal iron deciency is associated with babies with low weight (


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Health Organization,

Department of Nutrition for

Health and Development,

Geneva, Switzerland

(M de Onis MD);Imperial College

of London, St Marys Campus,

School of Public Health,

MRC-HPA Centre for

Environment and Health,

Department of Epidemiology

and Biostatistics, London, UK

(Pro M Ezzati PhD);Institute o

Child Health, University College

London, London, UK (Pro

S Grantham-McGregor FRCP); The

University o the West Indies,

Mona, Jamaica

(Pro S Grantham-McGregor);

Emory University, Atlanta, GA,

USA (Pro R Martorell PhD); and

London School of Hygiene and

Tropical Medicine, London, UK

(Pro R Uauy PhD)

Correspondence to:

Pro Robert Black, Johns Hopkins

University, Bloomberg School o

Public Health, Baltimore,

MD 21205, USA

[email protected]

The present Series is guided by a ramework (gure 1)that shows the means to optimum etal and child growthand development, rather than the determinants oundernutrition as shown in the conceptual modeldeveloped by UNICEF and used in the 2008 Series.1 Thisnew ramework shows the dietary, behavioural, andhealth determinants o optimum nutrition, growth, anddevelopment and how they are aected by underlyingood security, caregiving resources, and environmentalconditions, which are in turn shaped by economic andsocial conditions, national and global contexts, resources,and governance. This Series examines how thesedeterminants can be changed to enhance growth anddevelopment. These changes include nutrition-specicinterventions that address the immediate causes o

suboptimum growth and development. The rameworkshows the potential eects o nutrition-sensitive inter-ventions that address the underlying determinants omalnutrition and incorporate specic nutrition goalsand actions. It also shows the ways that an enablingenvironment can be built to support interventions andprogrammes to enhance growth and development andtheir health consequences. In the rst paper we assessthe prevalence o nutritional conditions and their healthand development consequences. We deem a lie-courseperspective to be essential to conceptualise the nutritionaleects and benets o interventions. The nutritionalstatus o women at the time o conception and duringpregnancy is important or etal growth and development,

and these actors, along with nutritional status in the rst2 years o lie, are important determinants o both

undernutrition in childhood and obesity and relateddiseases in adulthood. Thus, we organise this paper toconsider prevalence and consequences o nutritionalconditions during the lie course rom adolescence topregnancy to childhood and discuss the implications oradult health. In the second paper, we describe evidencesupporting nutrition-specic interventions and the healtheects and costs o increasing their population coverage.In the third paper we examine nutrition-sensitive inter-ventions and approaches and their potential to improvenutrition. In the ourth paper we examine the eatures oan enabling environment that are needed to providesupport or nutrition programmes and how they can beavourably changed. Finally, in a Comment6 we willexamine the desired national and global response to

address nutritional and developmental needs o womenand children in LMICs.

Prevalence and consequences o nutritionalconditionsAdolescent nutritionAdolescent nutrition is important to the health o girlsand is relevant to maternal nutrition. There are 12 billionadolescents (aged 1019 years)in the world, 90% o whomlive in LMICs. Adolescents make up 12% o the populationin industrialised countries, compared with 19% in LMICs(appendix p 2 shows values or ten countries studied indepth).7 Adolescence is a period o rapid growth andmaturation rom childhood to adulthood. Indeed, some

researchers have argued that adolescence is a periodwith some potential or height catch-up in children with

Figure 1: Framework or actions to achieve optimum etal and child nutrition and development

Morbidity andmortality in childhood

Cognitive, motor,socioemotional development

Breastfeeding, nutrient-rich foods, and eatingroutine

Nutrition specificinterventionsand programmes Adolescent health and

preconception nutrition Maternal dietary

supplementation

Micronutrientsupplementation orfortification

Breastfeeding andcomplementary feeding

Dietary supplementationfor children

Dietary diversification Feeding behaviours and

stimulation Treatment of severe acute

malnutrition Disease prevention and

management Nutrition interventions in

emergencies

Feeding and caregivingpractices, parenting,stimulation

Low burden ofinfectious diseases

Food security, includingavailability, economicaccess, and use of food

Feeding and caregivingresources (maternal,household, andcommunity levels)

Knowledge and evidencePolitics and governance

Leadership, capacity, and financial resourcesSocial, economic, political, and environmental context (national and global)

Access to and use ofhealth services, a safe andhygienic environment

School performanceand learning capacity

Adult stature

Obesity and NCDs

Work capacityand productivity

Benefits during the life course

Optimum fetal and child nutrition and development Nutrition sensitiveprogrammes and approaches Agriculture and food security Social safety nets Early child development Maternal mental health Womens empowerment

Child protection Classroom education Water and sanitation Health and family planning services

Building an enabling environment Rigorous evaluations Advocacy strategies Horizontal and vertical coordination Accountability, incentives regulation,

legislation Leadership programmes Capacity investments Domestic resource mobilisation

See Online or appendix


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stunting rom early childhood.8 Adolescent ertility isthree times higher in LMICs than in high-income coun-tries. Pregnancies in adolescents have a higher risk ocomplications and mortality in mothers9 and children10and poorer birth outcomes than pregnancies in olderwomen.10,11 Furthermore, pregnancy in adolescence willslow and stunt a girls growth.12,13 In some countries, asmany as hal o adolescents are stunted (height-or-ageZscore [HAZ]


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pregnancy was inversely associated with all-cause mater-nal mortality up to 42 days post-partum ater adjustingor numerous actors. An inverse association existsbetween maternal height and the risk o dystocia (dicultlabour), as measured by cephalopelvic disproportion orassisted or caesarean deliveries.1923

Figure 2 also shows trends or overweight and obesityin women aged 2049 years in dierent UN regions.Oceania, Europe, and the Americas had the highestproportion o overweight and obese women; howevernorthern and southern Arica, and central and west Asiaalso had high prevalences (appendix p 3).

Maternal obesity leads to several adverse maternal andetal complications during pregnancy, delivery, andpost-partum.24 Obese pregnant women (pre-pregnant

BMI 30 kg/m) are our times more likely to developgestational diabetes mellitus and two times more likely todevelop pre-eclampsia compared with women with aBMI 185249 kg/m2).2528 During labour and delivery,maternal obesity is associated with maternal death,haemorrhage, caesarean delivery, or inection;2931 and ahigher risk o neonatal and inant death,32 birth trauma,and macrosomic inants.3337 In the post-partum period,obese women are more likely to delay or ail to lactate andto have more weight retention than women o normalweight.38 Obese women with a history o gestationaldiabetes have an increased risk o subsequent typetwo diabetes, metabolic syndrome, and cardio vasculardisease.39 The early intrauterine environment has a role in

programming phenotype, aecting health in later lie.Maternal overweight and obesity at the time o pregnancyincreases the risk or childhood obesity that continuesinto adolescence and early adulthood, potentiating thetransgenerational transmission o obesity.40,41

Maternal vitamin decienciesAnaemia and ironAnaemia (haemoglobin


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previous analysis) showed that the odds ratio (OR) ormaternal deaths was 071 (95% CI 060085) or a10 g/L great

materna child nutrition

Documents