the lancet's maternal and child nutrition series, executive summary

7/28/2019 The Lancet's Maternal and Child Nutrition Series, Executive Summary

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Maternal and Child Nutrition

Executive Summary oThe Lancet Maternal and Child Nutrition Series

www.thelancet.com

Nutrition is crucial to both individual and national development. The evidence in

this Series urthers the evidence base that good nutrition is a undamental driver

o a wide range o developmental goals. The post-2015 sustainable development

agenda must put addressing all orms o malnutrition at the top o its goals


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Maternal and child undernutrition, consisting o

stunting, wasting and deciencies o essential

vitamins and minerals, was the subject o a Series

o papers in The Lancet in 2008.15 In the Series, we

quantied the prevalence o these issues, calculated

their short-term and long-term consequences, and

estimated their potential or reduction through

high and equitable coverage o proven nutrition

interventions.

The 2008 Series identied the need to ocus on the

crucial period rom conception to a childs secondbirthdaythe 1000 days in which good nutrition and

healthy growth have lasting benets throughout lie.

The Series also called or greater priority or national

nutrition programmes, stronger integration with health

programmes, enhanced intersectoral approaches, and

more ocus and coordination in the global nutrition

system o international agencies, donors, academia, civil

society, and the private sector.

5 years ater the initial series, we re-evaluate the

problems o maternal and child undernutrition and

also examine the growing problems o overweightand obesity or women and children and their

consequences in low-income and middle-income

countries (LMICs). Many o these countries are

said to have the double burden o malnutrition

continued stunting o growth and deciencies o

essential nutrients along with the emerging issue o

obesity. We also assess national progress in nutrition

programmes and international eorts toward previous

recommendations.

The rst paper6 examines the prevalence and

consequences o nutritional conditions during the lie

course rom adolescence (or girls) through pregnancy

to childhood and discusses the implications oradult health. The second paper7 covers the evidence

supporting nutrition-specic interventions and the

health outcomes and cost o increasing their population

coverage. The third paper8 examines nutrition-sensitive

interventions and approaches and their potential

to improve nutrition. The ourth paper9 discusses

the eatures o an enabling environment that are

needed to provide support or nutrition programmes,

and how they can be avourably inuenced. A set o

Comments1015 examine what is currently being done,

and what should be done nationally and internationallyto address nutritional and developmental needs o

women and children in LMICs.

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 eating

routine

Nutrition specificinterventionsand programmes

Adolescent health andpreconception nutrition

Maternal dietarysupplementation

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, economic

access, 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 and

hygienic 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

Maternal and Child Nutrition


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A new conceptual ramework

The present Series is guided by a ramework(gure 1) that shows the means to optimum etal

and child growth and development.6 This ramework

outlines the dietary, behavioural, and health

determinants o optimum nutrition, growth, and

development, and how they are aected by underlying

ood security, caregiving resources, and environmental

conditions, which are in turn shaped by economic

and social conditions, national and global contexts,

capacity, resources, and governance. The Series ocuses

on how these determinants can be changed to enhance

growth and development, including the nutrition-specic interventions that address the immediate

causes o suboptimum growth and development

and the potential eects o nutrition-sensitive

interventions that address the underlying determinants

o malnutrition and incorporate specic nutrition goals

and actions (panel 1). It also shows how an enabling

environment can be built to support interventions and

programmes to enhance growth and development.

An unnished agenda or undernutrition

The publication o The Lancet Maternal and ChildUndernutrition Series 5 years ago stimulated a

tremendous increase in political commitment to

reduction o undernutrition at global and national

levels. Most development agencies have revised their

strategies to address undernutrition ocused on the

1000 days during pregnancy and the rst 2 years o lie,

as called or in the 2008 Series. One o the main drivers

o this new international commitment is the Scaling Up

Nutrition (SUN) Movement.18,19 National commitment

in LMICs is growing, donor unding is rising and civil

society and the private sector are increasingly engaged.

However, this progress has not yet translated

into substantially improved outcomes globally.

Improvements in nutrition still represent a massive

unnished agenda. The 165 million children with

stunted growth have compromised cognitive

development and physical capabilities, making yet

another generation less productive than they would

otherwise be.6 Countries will not be able to break

out o poverty and to sustain economic advances

without ensuring their populations are adequately

nourished. Undernutrition reduces a nations economic

advancement by at least 8% because o direct

productivity losses, losses via poorer cognition, and

losses via reduced schooling.20

We cannot aord ornothing to change.

Burden o nutritional conditions

Undernutrition in LMICs

Stunted linear growth has become the main indicator o

childhood undernutrition, because it is highly prevalent

in nearly all LMICs, and has important consequences or

health and development. It should replace underweight

as the main anthropometric indicator or children. The

prevalence o stunting in children younger than 5 years

in LMICs in 2011 was 26%, a decrease rom 40% in

1990, and 32% in 2005, the estimate in the previous

nutrition series.1,6 The number o stunted children has

also decreased globally, rom 253 million in 1990, to 178

million in 2005, to 165 million in 2011. This represents

an average annual rate o reduction o 21%.6

The World Health Assembly (WHA) called or a 40%

reduction in the global number o children younger

than 5 years who are stunted by 2025 (compared with

the baseline o 2010).21 This aim would translate into a

39% reduction per year and imply reducing the number

o stunted children rom 171 million in 2010, to about

100 million in 2025.6 At the present rate o decline,

Panel1: Denition o nutrition-specic and nutrition-sensitive interventions

and programmes

Nutrition-specic interventions and programmes

Interventionsorprogrammesthataddresstheimmediatedeterminantso etal and

child nutrition and developmentadequate ood and nutrient intake, eeding,

caregiving and parenting practices, and low burden o inectious diseases

Examples:adolescent,preconception,andmaternalhealthandnutrition;maternal

dietaryormicronutrientsupplementation;promotionofoptimumbreastfeeding;

complementaryfeedingandresponsivefeedingpracticesandstimulation;dietary

supplementation;diversicationandmicronutrientsupplementationorforticationfor

children;treatmentofsevereacutemalnutrition;diseasepreventionandmanagement;

nutrition in emergencies

Nutrition-sensitive interventions and programmes

Interventionsorprogrammesthataddresstheunderlyingdeterminantsoffetalandchildnutritionanddevelopmentfoodsecurity;adequatecaregivingresourcesat

thematernal,householdandcommunitylevels;andaccesstohealthservicesanda

sae and hygienic environmentand incorporate specic nutrition goals and actions

Nutrition-sensitiveprogrammescanserveasdeliveryplatformsfornutrition-specic

interventions, potentially increasing their scale, coverage, and eectiveness

Examples:agricultureandfoodsecurity;socialsafetynets;earlychilddevelopment;

maternalmentalhealth;womensempowerment;childprotection;schooling;water,

sanitation,andhygiene;healthandfamilyplanningservices

Adapted rom Scaling Up Nutrition16 and Shekar and colleagues, 2013.17


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stunting is expected to reduce to 127 million, a 25%

reduction,in2025.EasternandwesternAfricaandsouth-central Asia have the highest prevalence of stunting;

the largest number o children aected by stunting,

69 million, live in south-central Asia. In Arica, only small

improvements are anticipated on the basis o present

trends, with the number o aected children increasing

rom 56 to 61 million, whereas Asia is projected to show

a substantial decrease in stunting prevalence.The prevalence o wasting was 8% globally in 2011,

aecting 52 million children younger than 5 years, an

11% decrease rom an estimated 58 million in 1990.6

The prevalence o severe wasting was 29%, aecting

19 million children.6 70% o the worlds children with

wasting live in Asia, most in south-central Asia, where

an estimated 15% (28 million) are aected.6

Deciencies o essential vitamins and minerals

are widespread and have substantial adverse eects

on child survival and development.6 Deciencies o

vitamin A and zinc adversely aect child health andsurvival, and deciencies o iodine and iron, together

with stunting, contribute to children not reaching their

developmental potential. Much progress has been made

in addressing vitamin A deciency but eorts must

continue at present coverage levels to avoid regressing

because dietary intake o vitamin A is still inadequate.

Additionally, micronutrient deciencies have an

important part to play in maternal health.6

Breasteeding practices are ar rom optimum,

despite improvements in some countries. Suboptimum

breasteeding results in an increased risk or mortalityin the rst 2 years o lie and results in 800 000 deaths

annually.6

Maternal, newborn, and child nutrition

New evidence urther reinorces the importance o the

nutritional status o women at the time o conception

and during pregnancy, both or the health o the mother

and or ensuring healthy etal growth and development.

32 million babies are born small-or-gestational-age

(SGA) annuallyrepresenting 27% o all births in LMICs.

Fetal growth restriction causes more than 800 000

deaths each year in the rst month o liemore than

a quarter o all newborn deaths.6 This new nding

contradicts the widespread assumption that babies who

are born SGA, by contrast with preterm babies, are not

at a substantially increased risk o mortality. Neonates

with etal growth restriction are also at substantially

increased risk o being stunted at 24 months and o

development o some types o non-communicable

diseases in adulthood.6

Undernutrition (etal growth restriction, suboptimum

breasteeding, stunting, wasting, and deciencies

o vitamin A and zinc) causes 45% o all deaths o

Key messages on disease burden due to nutritional conditions

Iron and calcium deciencies contribute substantially to maternal deaths

Maternal iron deciency is associated with babies with low weight (


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children younger than 5 years, representing more

than 3 million deaths each year (31 million o the69 million child deaths in 2011).6 Fetal growth

restriction and suboptimum breasteeding together

cause more than 13 million deaths, or 194% o all

deaths o children younger than 5 years, representing

435% o all nutrition-related deaths (table 1).

Good nutrition early in lie is also essential or children

toattaintheirdevelopmentalpotential;however,poor

nutrition oten coincides with other developmental

risks, in particular inadequate stimulation during early

childhood.6 Interventions to promote home stimulation

and learning opportunities in addition to good nutritionwill be needed to ensure optimum early development

and longer-term gains in human capital.6

This new evidence strengthens the case or a

continued ocus on the crucial 1000 day window during

pregnancy and the rst 2 years o lie. It also shows the

importance o intervening early in pregnancy and even

beore conception. Because many women do not access

nutrition-promoting services until month 5 or 6 o

pregnancy, it is important that women enter pregnancy

in a state o optimum nutrition. The emerging

platorms or adolescent health and nutrition mightoer opportunities or enhanced benets.7

There is a growing interest in adolescent health as

an entry point to improve the health o women and

children, especially as an estimated 10 million girls

younger than 18 years are married each year.6Evidence-

based interventions must be introduced in the pre-

conception period and in adolescents in countries

with a high burden o undernutrition and young age

atrstpregnancies;however,targetingandreachinga

sufcient number o those in need may be a challenge.

Prevention o maternal deaths

Iron and calcium deciencies contribute substantially

to maternal deaths. Previously reported analyses,

conrmed by this Series, showed that anaemia is a

risk actor or maternal deaths, probably because o

haemorrhage, the leading cause o maternal deaths

(23% o total deaths). Additionally there is now sound

evidence that calcium deciency increases the risk o

pre-eclampsia, currently the second leading cause o

maternal death (19% o total deaths). Thus, addressing

deciencies o these two minerals could result in

substantial reduction o maternal deaths.

Emerging burden o obesity

Overweight in adults and increasingly in childrenconstitutes an emerging burden that is quickly

establishing itsel globally, aecting both poor and rich

populations. The prevalence o maternal overweight

has increased steadily since 1980, and exceeds that

o maternal underweight in all regions o the world.

Maternal overweight and obesity result in increased

maternal morbidity and inant mortality.6

Overweight and obesity prevalence is increasing in

children younger than 5 years globally, especially in

developing countries, and is becoming an increasingly

important contributor to adult obesity, diabetes, andnon-communicable diseases.6 Although the prevalence

o overweight in high-income countries is more than

double that in LMICs, most aected children (76% o the

total number) live in LMICs. The trends in early childhood

overweight are a probably a consequence o changes in

dietary and physical activity patterns over time overlaid on

risks attributable to etal growth restriction and stunting.

I trends are not reversed, increasing rates o childhood

overweight and obesity will have vast implications, not

only or uture health-care expenditures but also or the

overall development o nations. These ndings conrmthe need or eective interventions and programmes

to reverse these anticipated trends. Early recognition

o excessive weight gain relative to linear growth is

essential.

Furthering the evidence to improve maternal

and child nutrition

Since the 2008 Series, many nutrition interventions

have been successully implemented at scale, and the

evidence base or eective interventions and delivery

strategies has grown. At the same time, coverage rates

or other interventions are either poor or non-existent.

We modelled ten nutrition-specic interventions

across the liecycle to address undernutrition and

micronutrient deciencies in women o reproductive

age, pregnant women, neonates, inants, and children

to assess the eects and cost o scaling up (gure 2).7

The invterventions were: periconceptual folic acid

supplementation, maternal balanced energy protein

supplementation, maternal calcium supplementation,

multiple micronutrient supplementation in

pregnancy, promotion o breasteeding, appropriate

complementary eeding, vitamin A and preventive


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zinc supplementation in children aged 659 months,

management o severe acute malnutrition (SAM), andmanagement o moderate acute malnutrition.

Continued investment in nutrition-specic inter-

ventions and delivery strategies to reach poor segments

o the population at greatest risk can make a substantial

dierence. I these ten proven nutrition-specic

interventions were scaled-up rom existing population

coverage to 90%, an estimated 900 000 lives could be

saved in 34 high nutrition-burden countries (where 90%

o the worlds stunted children live, gure 3) and the

prevalence o stunting could be reduced by 20% and that

o severe wasting by 60%. This would reduce the numbero children with stunted growth and development by

33 million.7 On top o existing trends, this improvement

would comortably reach the WHA targets or 2025.

Cost o scaling up proven interventions

We estimate that the cost o scaling-up this package

o ten essential nutrition-specic interventions to

90% coverage in 34 countries is US$96 billion per

year (table 2).7 O the $96 billion, $37 billion (39%)is or micronutrient interventions, $09 billion (10%)

or educational interventions, and $26 billion (27%)

or management o SAM. The remaining $23 billion

(24%) accounts or provision o ood or pregnant

women and children aged 623 months in poor

households. Since many interventions are being scaled

up from negligible coverage, the cost is reasonable;

the cost per discounted lie-year saved is about

$370 ($213 per undiscounted lie-year saved).

More than hal the $96 billion is accounted or by

two large countries which will rely heavily on domesticresources (India and Indonesia). Consumables (drugs,

or other items such as or transport or administration)

account or a little less than hal o the $96 billion, and

all but the poorest countries can be expected to cover

most o the expenditures on personnel. Thereore,

$34 billion rom external donors could make a

substantial dierence to child nutrition

Preconception care: familyplanning, delayed age at first

pregnancy, prolonging ofinter-pregnancy interval,abortion care, psychosocial care

Folic acid supplementation Multiple micronutrient

supplementation Calcium supplementation Balanced energy protein

supplementation Iron or iron plus folate Iodine supplementation Tobacco cessation

Delayed cord clamping Early initiation of breast

feeding Vitamin K administration Neonatal vitamin A

supplementation Kangaroo mother care

Exclusive breast feeding Complementary feeding

Vitamin A supplementation(659 months)

Preventive zincsupplementation

Multiple micronutrientsupplementations

Iron supplementation

WRA and pregnancy Neonates Infants and children

Malaria prevention inwomen

Maternal deworming Obesity prevention

Disease prevention andtreatment

Management of SAMManagement of MAM Therapeutic zinc for

diarrhoea WASH Feeding in diarrhoea Malaria prevention

in children

Deworming in children Obesity prevention

Disease prevention andtreatment

Increased workcapacityand productivity

Economicdevelopment

Decreased maternaland childhoodmorbidity andmortality

Improved cognitivegrowth andneurodevelopmentaloutcomes

Delivery platforms: Community delivery platforms, integrated management of childhood illnesses, child health days, school-baseddelivery platforms, financial platforms, fortification strategies, nutrition in emergencies

Adolescent

Bold=Interventions modelled

Italics=Other interventions reviewed

Figure 2: Conceptual ramework

WRA=women o reproductive age. WASH=water, sanitation, and hygiene. SAM=severe acute malnutrition. MAM=moderate AM.


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The promise o emerging interventions and delivery

strategies and platorms

Delivery strategies are crucial to achieving coverage

with nutrition-specic interventions and reaching

populations in need. A range o channels can provide

opportunities or scaling up and reaching largepopulation segments, such as ortication o staple

oods and conditional and unconditional cash transers.7

Community delivery platorms or nutrition education

and promotion, integrated management o childhood

illness, school-based delivery platorms, and child health

days are other possible channels.

Innovative delivery strategiesespecially community-

based delivery platormsare promising or scaling

up coverage o nutrition interventions and have the

potential to reach poor and difcult to access populations

through communication and outreach strategies.7 These

could also lead to potential integration o nutrition with

maternal, newborn, and child health interventions,

helping to achieve reductions in inequities.

Unlocking the potential o nutrition-sensitive

programmes

In addition to nutrition-specic interventions,

acceleration o progress in nutrition will also require

increases in the nutritional outcomes o eective, large-

scale, nutrition-sensitive development programmes.8

Nutrition-sensitive programmes address key underlying

determinants o nutritionsuch as poverty, ood

insecurity, and scarcity o access to adequate care

resourcesand include nutrition goals and actions. They

can thereore help enhance the eectiveness, coverage,

and scale o nutrition-specic interventions.

Our review o potentially nutrition-sensitive

programmes in agriculture, social saety nets, early child

Ethiopia

Kenya

Tanzania

Yemen

South Africa

Madagascar

Zambia

Angola

CongoRwanda

Uganda

MozambiqueMalawi

Sudan

Chad

NigerMali

Burkina Faso

Cte dIvoireGhana

Nigeria

Cameroon

Pakistan

Egypt

Afghanistan

Iraq

India

Nepal

Bangladesh

Myanmar

Vietnam

Philippines

Indonesia

High burden countries

Other countries

Guatemala

Figure 3: Countries with the highest burden o malnutrition

These 34 countries account or 90% o the global burden o malnutrition.

Number o lives

saved*

Cost per lie-year

saved

Optimum maternal nutrition during pregnancy

Maternal multiple micronutrient supplements to all

Calcium supplementation to mothers at risk o low intake

Maternal balanced energy protein supplements as needed

Universal salt iodisation

102 000

(49 000146 000)

$571 (3981191)

Inant and young child eeding

Promotion o early and exclusive breasteeding or 6 months and

continued breasteeding or up to 24 months

Appropriate complementary eeding education in ood secure

populations and additional complementary ood supplements in

ood insecure populations

221 000

(135 000293 000)

$175 (132286)

Micronutrient supplementation in children at risk

Vitamin A supplementation between 6 and 59 months age

Preventive zinc supplements between 12 and 59 months o age

145 000

(30 000216 000)

$159 (106766)

Management o acute malnutrition

Management o moderate acute malnutrition

Management o severe acute malnutrition

435 000

(285 000482 000)

$125 (119152)

Data are number (95% CI) or cost in 2010 international dollars (95% CI) . *Eectofeachofpackagewhenallfour

packages are scaled up at once. Cost per lie-year saved assumes that a lie saved o a child younger than 5 years saves on

average 59 lie-years, based on WHO data (2011188) that lie expectancy at birth on average in low-income countries is 60,

and that most deaths o children younger than 5 years occur in the rst year o lie. To convert to cost per discounted lie-

year saved multiply these estimates by 59/32 (ie, 184).Intervention has eect on maternal or child morbidity, but no

direct eect on lives saved.Cost per lie-year saved by management o severe acute malnutrition only, costs or

supplementary eeding or moderate acute malnutrition are currently unavailable.

Table 2: Efect o packages o nutrition interventions at 90% coverage


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development, and schooling conrms that programmes

in these sectors are successul at addressing several othe underlying determinants o nutrition, but evidence

o their nutritional eect is still scarce.

Targeted agricultural programmes have an important

role in support o livelihoods, ood security, diet

quality, and womens empowerment, and complement

global eorts to stimulate agricultural productivity

and thus increase producer incomes while protecting

consumers rom high ood prices.8 Evidence of eect

on nutrition outcomes, however, is inconclusive, with

the exception o eects on vitamin A intake and status

rom homestead ood production programmes anddistribution o bioortied vitamin A-rich orange sweet

potato. Evidence suggests that targeted agricultural

programmes are more successul when they incorporate

strong behaviour change communications strategies

and a gender-equity ocus. Although rm conclusions

have been hindered by a dearth o rigorous programme

evaluations, weaknesses in programme design and

implementation also contribute to the limited evidence

o nutritional outcomes so ar.

Key messages on nutrition-specic interventions

A clear need exists to introduce promising evidence-

based interventions in the preconception period and in

adolescents in countries with a high burden o

undernutritionandyoungageatrstpregnancies;

however, targeting and reaching a sufcient number o

those in need will be challenging.

Promising interventions exist to improve maternal

nutrition and reduce intrauterine growth restriction and

small-or-gestational-age (SGA) births in appropriate

settings in developing countries, i scaled up beore and

during pregnancy. These interventions include balanced

energy protein, calcium, and multiple micronutrient

supplementation and preventive strategies or malaria in

pregnancy

Replacement o iron-olate with multiple micronutrient

supplements in pregnancy might have additional benets

or reduction o SGA in at-risk populations, although

urther evidence rom eectiveness assessments might be

needed to guide a universal policy change.

Strategies to promote breasteeding in community and

acility settings have shown promising benets on

enhancingexclusivebreastfeedingrates;however,

evidence or long-term benets on nutritional and

developmental outcomes is scarce.

Evidencefortheeectivenessofcomplementaryfeeding

strategies is insufcient, with much the same benetsnoted rom dietary diversication and education and

ood supplementation in ood secure populations and

slightly greater eects in ood insecure populations.

Further eectiveness trials are needed in ood insecure

populations with standardised oods (pre-ortied or

non-ortied) to assess duration o intervention,

outcome denition, and cost eectiveness.

Treatment strategies or severe acute malnutrition with

recommended packages o care and ready-to-use

therapeutic oods are well established, but urther

evidence is needed or prevention and management

strategies or moderate acute malnutrition in population

settings, especially in inants younger than 6 months.

Data or the eect o various nutritional interventions

onneurodevelopmentaloutcomesisscarce;future

studies should ocus on these aspects with consistency

in measurement and and reporting o outcomes.

Conditional cash transers and related saety nets can

address the removal o nancial barriers and promotion

o access o amilies to health care and appropriate

oods and nutritional commodities. Assessments o the

easibility and eects o such approaches are urgently

needed to address maternal and child nutrition in well

supported health systems.

Innovative delivery strategies, especially

community-based delivery platorms, are promising or

scaling up coverage o nutrition interventions and have

the potential to reach poor populations through demand

creation and household service delivery.

Nearly 15% o deaths o children younger than 5 years

can be reduced (ie, 1 million lives saved), i the ten core

nutrition interventions we identied are scaled up.

The maximum eect on lives saved is noted with

management o acute malnutrition (435 000

[range285000482000]livessaved);221000

(135 000293 000) lives would be saved with delivery o

an inant and young child nutrition package, including

breasteeding promotion and promotion o

complementaryfeeding;micronutrientsupplementationcould save 145 000 (30 000216 000) lives.

These interventions, i scaled up to 90% coverage,

could reduce stunting by 203% (33.5 million ewer

stunted children) and can reduce prevalence o severe

wasting by 614%.

The additional cost o achieving 90% coverage o these

proposed interventions would be US$96 billion per year.


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Social saety nets provide cash and ood transers

to a billion poor people and reduce poverty. They alsohave an important role in mitigation o the negative

eects o global changes, conicts, and shocks by

protecting income, ood security, and diet quality. When

targeted to women, they enhance several aspects o

womens empowerment. Pooled evidence, however,

shows limited eects o these programmes on child

nutrition, although some individual studies showed

eects in younger and poorer children exposed or

longer durations.8 Absence o clarity in nutrition goals,

weaknesses in design, and poor quality services probably

account or the limited nutritional eects.Child stunting and impaired cognitive development

share many o the same risk actors including nutritional

deciencies, intra-uterine growth restriction, and social

and economic conditions, such as poverty and maternal

depression.6 Linear growth and cognitive development

also share the same period o peak vulnerability

the rst 1000 days o lie. Combination o early child

development and nutrition interventions thereore

makes sense biologically and programmatically, and

evidence rom mostly small-scale programmes suggests

additive or synergistic eects on child development andin some cases on nutrition outcomes.8

Interventions to improve maternal mental health also

have high potential or nutritional eects and should

be incorporated in nutrition-sensitive programmes.8

Maternal depression is an important determinant o

suboptimum caregiving and health-seeking behaviours

and is associated with poor nutrition and child

development outcomes.

Parental schooling is consistently associated with

improved nutrition outcomes and schools provide an

opportunity, so ar largely untapped, to include nutrition

in school curricula or prevention and treatment

o undernutrition or obesity.8 Nutrition-sensitive

programmes also oer a unique opportunity to reach girls

in adolescence (preconception) and possibly to achieve

scale either through school-linked programmes with

conditions or home-based programmes.

The potential o nutrition-sensitive programmes to

improve nutrition outcomes is clear, but it has yet to

be unleashed. Importantly, several o the programmes

documented in our analysis8 were not originally

designed with clear nutrition goals and actions rom the

outset and were retrotted to be nutrition-sensitive. The

nutrition-sensitivity o programmes can be enhanced

by:improvedtargeting;useofconditionstostimulate

demand for programme services; strengthening of

nutrition goals, design, and implementation; and

optimisation o womens nutrition, time, physical and

mental health, and empowerment.

With guidance on how nutrition-sensitivity can be

enhanced and a new generation o nutrition-sensitive

programmes, stronger evidence should emerge in the

near uture. Currently, new agriculture, social saety

net programmes, and joint nutrition and early child

development programme designs, methods, and

packages o interventions are being tested, several o

Key messages on nutrition-sensitive interventions and programmes

Nutrition-sensitiveinterventionsandprogrammesinagriculture,socialsafetynets,early

child development, and education have enormous potential to enhance the scale and

eectivenessofnutrition-specicinterventions;improvingnutritioncanalsohelp

nutrition-sensitive programmes achieve their own goals.

Targetedagriculturalprogrammesandsocialsafetynetscanhavealargerolein

mitigation o potentially negative eects o global changes and man-made and

environmental shocks, in supporting livelihoods, ood security, diet quality, and womens

empowerment, and in achieving scale and high coverage o nutritionally at-risk

households and individuals.

Evidenceoftheeectivenessoftargetedagriculturalprogrammesonmaternalandchild

nutrition,withtheexceptionofvitaminA,islimited;strengtheningofnutritiongoals

and actions and rigorous eectiveness assessments are needed.

ThefeasibilityandeectivenessofbiofortiedvitaminA-richorangesweetpotatofor

increasingmaternalandchildvitaminAintakeandstatushasbeenshown;evidenceof

the eectiveness o bioortication continues to grow or other micronutrient and crop

combinations.

Socialsafetynetsareapowerfulpovertyreductioninstrument,buttheirpotentialto

benetmaternalandchildnutritionanddevelopmentisyettobeunleashed;todoso,

programme nutrition goals and interventions, and quality o services need to be

strengthened.

Combinationsofnutritionandearlychilddevelopmentinterventionscanhaveadditive

or synergistic eects on child development, and in some cases, nutrition outcomes .

Integration o stimulation and nutrition interventions makes sense programmatically

and could save cost and enhance benets or both nutrition and development outcomes.

Parentalschoolingisconsistentlyassociatedwithimprovednutritionoutcomesand

schools provide an opportunity, so ar untapped, to include nutrition in school curricula

or prevention and treatment o undernutrition or obesity. Maternaldepressionisanimportantdeterminantofsuboptimumcaregivingand

health-seeking behaviours and is associated with poor nutrition and child development

outcomes;interventionstoaddressthisproblemshouldbeintegratedin

nutrition-sensitive programmes.

Nutrition-sensitiveprogrammesoerauniqueopportunitytoreachgirlsduring

preconception and possibly to achieve scale, either through school-linked conditions and

interventions or home-based programmes.

Thenutrition-sensitivityofprogrammescanbeenhancedbyimprovingtargeting;using

conditions;integratingstrongnutritiongoalsandactions;andfocusingonimproving

womens physical and mental health, nutrition, time allocation, and empowerment.


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Executive Summary

10 www.thelancet.com

which integrate complementary inputs that address other

constraints to optimum nutritionsuch as maternaldepression, or scarcity o access to water, sanitation, and

hygiene servicesand are strengthening links with health

services. Rigorous impact evaluations are underway,

many o which are based on strong programme theory

and impact pathway analysis. They are also addressing

key weaknesses encountered in previous evaluations and

are assessing outcomes on a range o nutrition and child

development outcomes as well as several household and

gender outcomes along the impact pathway. The body

o evidence generated by these enhanced programmes

and evaluations in the next 510 years will be o crucialimportance to inorm uture investments in nutrition-

sensitive programmes rom many sectors.

Building an enabling environment to deliver

nutrition results

The nutrition landscape has shited undamentally since

2008. The 2008 Series showed that the stewardship

o the nutrition system was dysunctional and deeply

ragmented in terms o messaging, priorities, and

unding.5 Much progress has been made since then,largely driven by the new evidence introduced in the

2008 Series, which identied the rst 1000 days o lie

as the window or outcomes, pinpointed a package

o highly eective interventions or reduction o

undernutrition, and proposed a group o high-burden

countries as priorities or increased investment.

The launch o the SUN Movement in 2010 represented

a major step toward improved stewardship o the global

nutrition architecture.18,19 SUN brings together more

than 100 entities across the organisational spectrum

o the nutrition community. Up to now, more than 30countries (representing 35% o the global child stunting

burden) have joined SUN, committing to scaling-up direct

nutrition interventions and advancing nutrition-sensitive

development. Although it is too soon to evaluate SUNs

eect on rates o reduction o undernutrition, it is clear

that through SUN, many countries have made advances

in building multistakeholder platorms across sectors,

aligning nutrition-relevant programmes within a common

results ramework, and mobilising national resources.

Additionally, nutrition has been greatly elevated on the

global agenda. Nearly every major development agencyhas published a policy document on undernutrition, and

donors have increased ofcial development assistance

to basic nutrition by more than 60% between 2008 and

2011, in a very difcult scal climate. Nutrition is now

more prominent on the agendas o the UN, the G8 and

G20, and supporting civil society.

Nowadays, the impetus or improving nutrition is

even stronger than it was 5 years ago. The WHA targets

or reducing stunting, wasting, low birthweight,

anaemia, and overweight, and increasing exclusive

breasteeding in the rst 6 months o lie can be

achieved by 2025 with sufcient support.21 Central to

this scaled-up support is the creation o an enabling

environment to build commitment and ensure that it is

translated into outcomes.

Improvement o data, research, and accountability or

results

The availability o timely and credible nutrition data,

presented in accessible ways, can help governments

and other actors to be responsive to challenging

circumstances, and help civil society organisations

to hold them accountable or the eectiveness o

Key messages on enabling environments or nutrition

Emergingcountryexperiencesshowthatratesofundernutritionreductioncanbeaccelerated with deliberate action

Politiciansandpolicymakerswhowanttopromotebroad-basedgrowthandprevent

human suering should prioritise investment in scale-up o nutrition-specic

interventions, and should maximise the nutrition sensitivity o national

development processes

Findingsfromstudiesofnutritiongovernanceandpolicyprocessesbroadlyconcuron

threefactorsthatshapeenablingenvironments:knowledgeandevidence,politicsand

governance, and capacity and resources

Framingofundernutritionreductionasanapoliticalissueismyopicandself-

deeating. Political calculations are at the basis o eective coordination between

sectors, national and subnational levels, private sector engagement, resource

mobilisation, and state accountability to its citizens

Politicalcommitmentcanbedevelopedinashorttime,butcommitmentmustnotbe

squanderedconversion to results needs a dierent set o strategies and skills Leadershipfornutrition,atalllevels,andfromavarietyofperspectives,is

undamentally important or creating and sustaining momentum and or conversion

o that momentum into results on the ground.

Accelerationandsustainingofprogressinnutritionwillnotbepossiblewithout

national and global support to a long-term process o strengthening systemic and

organisational capacities

Theprivatesectorhassubstantialpotentialtocontributetoaccelerationof

improvements in nutrition, but eorts to realise this have to date been hindered by a

scarcity o credible evidence and trust. Both these issues need substantial attention i

the positive potential is to be realised

Operationalresearchofdelivery,implementation,andscale-upofinterventions,and

contextual analyses about how to shape and sustain enabling environments, is

essential as the ocus shits toward action


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Executive Summary

www.thelancet.com 11

their interventions.9 Advances in health management

inormation systems and the growing availabilityo newer technologies can help with the real-time

monitoring o nutrition outcomes and programme

coverage and quality, and should be researched.

Additionally, although much progress has been made

to work out the costs o addressing undernutrition,

continued work to contextualise and speciy these costs

or dierent countries is essential, along with stronger

designation o donor and government spending to

improve tracking o investments and results in nutrition.

Improved data or micronutrient deciencies and

other nutritional conditions are needed at national andsubnational levels. This improvement should involve

the development and use o improved biomarkers

that could be used to describe nutritional conditions

and increase knowledge o how they aect health and

development. Such inormation is needed to guide

intervention programmes in countries and priorities or

support globally.

Although substantial progress has been made

to establish the needs around nutrition, no

systematic process exists or bringing together the

implementation-related evidence or how to scaleup the vast array o nutrition-specic and nutrition-

sensitive interventions with quality and equity (so-

called implementation science). This evidence is

essential to ensure that uture investments are directed

toward proven pathways to outcomes.

Beyond this evidence, service providers, governments,

donors, and the private sector need strong national

monitoring and assessment platorms to hold them

accountable or the quality and eectiveness o

their investments in nutrition.9 Boosting nutrition

commitment and accountability can be achieved

through assessing and implementing innovative new

instruments and mechanisms, including computer-

based monitoring systems, commitment indices, and

social accountability mechanisms.

Engagement and regulation o the private sector

The scale, know-how, reach, nancial resources, and

existing involvement o the private sector in actions that

aect nutrition status is well known.9 Yet there are still

too ew independent and rigorous assessments o the

eectiveness o involvement o the commercial sector

in nutrition. Distrust o the private sectorespecially

the ood industryremains high and is linked, partly,

to the decades-long tussle related to the marketingo breastmilk substitutes in developing countries and

around continued marketing o sugar-sweetened

beverages and ast oods worldwide.

This troubled history has made it more difcult or the

private sector to be a major contributor to the collective

creation and sustenance o momentum or reduction

o malnutrition. In view o the needs and substantial

resources, inuence, and convening power o the

private sector, it might represent a missed opportunity.

Opportunities exist or collaboration around advocacy,

monitoring, value chains, technical and scienticcollaboration, and staple-ood ortication that are

uncontentious and deserve urther exploration. Know-

ledge in this area must be expanded rapidly to guide the

private sector toward more positive eects or nutrition.

Regulatory and scal eorts are essential when the

private sector is involved in marketing o products that

are detrimental to optimum nutrition. The experience

gained with the International Code o Marketing

o Breastmilk Substitutes should be applied to the

promotion o other harmul, widely-consumed ood

products that are being marketed or young children.

Mobilisation o resources

High-burden countries, together with donors,

multilaterals, and the private sector, have a responsibility

to increase allocations to nutrition-specic and

nutrition-sensitive programmes. Meeting the estimated

$96 billion nancing gap will require an increase in

donor spending, alongside an equal or greater increase

o spending by LMICs and the establishment o nutrition

budget lines in all high-burden countries.7 To achieve this

aim will be politically challenging, hence the need to build

leadership, commitment, and accountability at national

and international levels.9 However, the nancing gap is

unlikely to be closed by these sources alone. Innovation

is needed across all sectors to leverage private-sector and

public-sector resources and generate additional unding.

The nutrition sector can draw on several innovative ideas

rom other sectors, including advance market contracts

to promote investment, market levies, and taxes in the

eort. Additional resources must be directed not only to

interventions, but also to the creation o environments

to enable advancement o nutrition, including capacity

and leadership at all levels o government.9 A political


12/12

Executive Summary

economy approach to prioritisation o such investments

is crucial i sustainable, supportive environments orlong-term nutrition agendas are to be created.

Nutrition is crucial to both individual and national

development. The evidence in this Series urthers the

evidence base that good nutrition is a undamental

driver o a wide range o development goals. The

post-2015 sustainable development agenda must put

addressing all orms o malnutrition at the top o its

goals.

Now is our crucial window o opportunity to scale-

up nutrition.22 National and international momentum

to address human nutrition and related ood securityand health needs has never been higher. We must work

together to seize this opportunity.

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Acknowledgments

Maternal and Child Nutrition Study Group:RobertEBlack(JohnsHopkinsBloomberg

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 Victora (Universidade Federal de Pelotas, Brazil), Susan Walker (The University

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

Funding: Funding or the preparation o the Series was provided to the Johns

Hopkins School o Public Health through a grant rom the Bill & Melinda Gates

Foundation. The sponsor had not role in analysis or interpretation o the evidence.

Coverimagecopyright:Corbis

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9 Gillespie S, Haddad L, Mannar V, Menon P, Nisbettt N, and the Maternal andChildNutritionStudyGroup.Thepoliticsofreducingmalnutrition:buildingcommitment and accelerating progress. Lancet2013;publishedonlineJune6.http://dx.doi.org/10.1016/S0140-6736(13)60842-9.

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13 Taylor A, Dangour AD, Reddy KS. Only collective action will endundernutrition.Lancet2013;publishedonlineJune6.http://dx.doi.

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17 ShekarM,Ruel-BergeronJ,HerforthA.ModuleA.Introduction.In:Improvingnutrition through multisectoral appraoches. Washington, DC, InternationalBank or Reconstruction and Development, International DevelopmentAssociation o The World Bank, 2013.

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19 BezansonK,IsenmanP.Scalingupnutrition:aframeworkforaction.FoodNutr Bull2010;31: 17886.

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the lancet's maternal and child nutrition series, executive summary

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