Nutrition: The Lancet

The Lancet: Maternal and Child Undernutrition

Website: http://go.worldbank.org/7Q8VB5QK90

The new Lancet series on nutrition, co-authored and co-financed by the World Bank, depicts the lamentable state of under-nutrition worldwide, and a corresponding negligence on the part of the development community to meet the challenge decisively. Under-nutrition represents the non-income face of poverty. And the world is off track on meeting this goal.

More than a third of child deaths and 11% of the total disease burden worldwide are due to maternal and child undernutrition. These and other stark findings are the conclusions of an international collaboration of investigators publishing their findings in The Lancet's maternal and child undernutrition series.

The series was launched in London on January 16, 2008 at the Science and Media Centre

Nutrition has slipped through the gap
Nutrition is a desperately neglected aspect of maternal, newborn, and child health. The reasons for this neglect are understandable but not justifiable. In a comment that opens the maternal and child undernutrition series, The Lancet Editor Dr Richard Horton draws together the themes of the series, and calls on agencies, donors and political leaders to step up to this very serious challenge. He says "Undernutrition is the largely preventable cause of over a third - 3.5 million - of all child deaths. Stunting, severe waste wasting and intrauterine growth restriction are among the most important problems. There is a golden interval for intervention: from pregnancy to 2 years of age. After age 2 years, undernutrition will have caused irreversible damage for future development towards adulthood". The comment concludes by saying that the international nutrition system is broken. Leadership is absent, resources are too few, capacity is fragile, and emergency response systems are urgently needed.

Over a third of child deaths and 11% of global disease burden due to maternal and child undernutrition
More than one third of child deaths and 11% of the total disease burden worldwide are due to maternal and child undernutrition. Authors of the first paper in the series say "Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in substantial increases in mortality and overall disease burden." By doing an analysis that accounted for co-exposure of nutrition-related factors, the authors found that these factors were together responsible for 35% of child deaths globally and 11% of the total disease burden. The paper concludes by making a compelling case for the urgent implementation of interventions to reduce their occurrence or ameliorate their consequences.

Poor fetal growth or stunting in first two years of life leads to huge negative consequences in later life
Authors of the second paper of the series conclude that poor fetal growth or stunting in the first two years of life can lead to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income and decreased offspring birthweight for women. The researchers analysed the association between child and maternal undernutrition with human capitol and risk of adult disease in low-and-middle-income countries, focussing on five long-standing studies in Brazil, Guatemala, India, the Philippines, and South Africa. They showed that indicators of undernutrition at age two years were related to adult outcomes. Further, they found that children who are undernourished in the first two years of life, and who put on weight rapidly later in childhood and in adolescence are at a high risk of chronic diseases related to nutrition. But they found no evidence that rapid weight gain or height gain in the first two years life increases the risk of chronic disease, even in children with poor fetal growth. The authors conclude by saying "...damage suffered in early life leads to permanent impairment, and might also affect future generations. Its prevention will probably bring about important health, educational, and economic benefits."

Maternal and child nutrition interventions could prevent a quarter of child deaths in poor communities
Implementation of existing maternal and child nutrition-related interventions could prevent a quarter of all child deaths in the 36 countries with the highest burden of undernutrition. Breastfeeding counselling and vitamin A supplementation are currently the nutrition strategies with the greatest potential to cut child deaths, comment the authors of the third paper in the series. The authors studied how a variety of nutritional factors affected children's growth patterns and risk of death. In populations with enough food, education about complimentary feeding increased the height-for-age score, while provision of food supplements increased the score further in food-insecure populations. Further, the authors also found that management of severe acute malnutrition using WHO guidelines can reduce case-fatalities related to this condition by 55%, but this requires admission to a health facility. The authors add that nutrition strategies on their own are not enough, concluding by saying "Attention to the continuum of maternal and child undernutrition is essential to attainment of several of the Millennium Development Goals and must be prioritised globally and within countries... What is needed is the technical expertise and the political will to combat undernutrition in the very countries that need it most."

80% of world's undernourished children live in just 20 countries
Authors of the fourth paper in the series highlight how 80% of the world's undernourished children live in just 20 countries, and intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal and greatly increase the chances of achieving goals for child and maternal mortality. They address seven key challenges for addressing undernutrition at national level, including; getting nutrition on the list of priorities, and also keeping it there. The paper looks at the varied situation within and across Latin American countries, which as a whole have experienced a large drop in stunting, being underweight, and wasting; and China, where a multisectoral approach has seen rapid nutritional improvement. The authors caution that nutrition resources should not be used to support actions unlikely to be effective in real life setting of a particular country, nor to support actions that have not been proven to have a direct effect on undernutrition They conclude by asking "What can be done?...there are no simple prescriptions to reduce undernutrition, although high coverage with four or five of the proven interventions would certainly have a sizeable effect", charging leaders at country level to review their existing strategies and programmes.

The international nutrition system: fragmented, dysfunctional and desperately in need of reform
The final paper in the series states that the international nutrition system - made up of international and donor organisations, academia, civil society, and the private sector - is fragmented and dysfunctional, and needs reform, say authors of the fifth and final paper in the series. They say: "Financial, intellectual, and personal linkages bind these organisations loosely together as components of an international nutrition system... we argue that such a system should deliver in four functional areas: stewardship, mobilisation of financial resources, direct provision of nutrition services at times of natural disaster or conflict, and human and institutional resource strengthening." Their analysis of evidence to date finds that currently, there are substantial shortcomings in each of the areas above. Fragmentation, lack of evidence for prioritised action, institutional inertia, and failure to join up with promising developments in parallel sectors are recurrent themes. Many problems are systemic within organisations in the field. They suggest five priority areas for action to create a much stronger international nutrition system, and call for research leadership in areas that matter. The authors conclude by saying "The moment is ripe for these reforms. Their implementation would transform the political salience of undernutrition, and offer the chance of a better, more productive life to the 67 million children born each year in the countries most severely afflicted by undernutrition."



Other Articles in the series:

The Challenge of hunger, Josette Sheeran.

Nutrition interventions need improved operational capacity, Geert Tom Heikens, Beatrice C Amadi, Mark Manary.

The speakers at the event were:

Dr Richard Horton, Editor, The Lancet
Professor Zulfiqar Bhutta, Department of Pediatrics and Child Health, Aga Khan University Pakistan
Professor Caroline Fall, Medical Research Council Epidemiology Resource Centre, University of Southampton, UK
Professor Simon Cousens, London School of Hygiene and Tropical Medicine, UK
Dr Denise Coitinho, WHO on temporary secondment to World Food Programme
Dr Bruce Cogill, UNICEF



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