Achieving Freedom from Maternal Achieving Freedom from Maternal and Child Undernutrition: and Child Undernutrition:

An Update on The Lancet Series  An Update on The Lancet Series  

34th Session of the Standing Committee on Nutrition:Working Together

Third SessionMonday, 26 February

Saul S. MorrisLondon School of Hygiene & Tropical Medicine (Honorary)

Outline

Series basics

Progress in the three streams of series activity

Revised timeline

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Series BasicsSeries Basics

Series objectives

Provide evidence of the importance and determinants of maternal and child undernutrition in global health

Provide evidence of the effectiveness of nutrition interventions and programs with respect to mortality, morbidity and human potential

Place nutrition interventions within a broader context of policies and programs that may affect nutrition and health

Series objectives - 2

Assess the correspondence between existing priorities and funding and opportunities for nutritional interventions to improve health and nutrition

Provide recommendations on national/subnational actions with respect to nutritional interventions

Provide recommendations for improved institutional arrangements and policies relating to nutrition at global level

of activity

Broad engagement of the global nutrition and health communities and interaction with the global food community

Technical reviews, analyses, and writing the series contents

Wide dissemination of and advocacy based on series findings

The Maternal and Child Undernutrition Study Group

Linda AdairTahmeed AhmadLindsay AllenZulfiqar Bhutta*Robert Black**Martin BloemJennifer Bryce*Laura CaulfieldDenise CoitinhoSimon CousensIan Darnton-HillMercedes de OnisMajid EzzatiBruce CogillBoitshepo Giyose

Pedro HallalBetty KirkwoodReynaldo MartorellSaul Morris*David PelletierPer Pinstrup-AndersonLinda RichterJuan RiveraMarie RuelHarshpal SachdevMeera ShekarRoger ShrimptonRicardo UauyCesar Victora*

With contributions from many others who will be acknowledged in the individual papers.

*Writing team leader for one of the series papers; **Series Coordinator and writing team leader.

Maternal & childundernutrition

DiseaseInadequate

dietary intake

Unhealthy household environment & lack of

health services

Inadequate care

Household food

insecurity

Lack of capital: financial, human, physical, social and natural

Social, economic and political context

Adapted from UNICEF, 1998

Immediatecauses

Underlyingcauses

Basiccauses

Income poverty: employment, self-employment, dwelling, assets, remittances,

pensions, transfers, etc.

Short-term consequences:Mortality, morbidity, disability

Long-term consequences:Adult size, intellectual ability, economic productivity,

reproductive performance, metabolic and cardiovascular disease

Conceptual framework for the series

Terminology

Undernutrition = stunting, wasting and deficiencies in essential vitamins and minerals

Malnutrition = undernutrition or obesity

Disability-Adjusted Life Years (DALYs) = a standardised approach to epidemiological assessment that includes estimates of the burden of a disorder in terms of mortality, incidence, average age of onset, duration, and disability severity.

Focus countries for the series

Stunting prevalence > 20%

Rank order by number of stunted children, and begin counting with the country with the greatest number

36 countries that account for 90% of stunted children worldwide (Papers 1, 3 and coverage in 4)

20 countries accounting for 80% of stunted children worldwide (Papers 4 & 5)

Progress in the Progress in the three of series activitythree of series activity

Broad engagement of the global nutrition and health communities, and interaction with the global food community

Individual papers in the series

Contributions from dozens of individuals provision of data

analyses

technical consultations  

Broad engagement of the global nutrition and health communities, and interaction with the global food community - 2

The series as a whole

Consultative meeting, Baltimore, March 2006 Announcement at March 2006 SCN meeting Invitation for comment, SCN News (mid-2006)Meeting, UNICEF Innocenti Centre, September 2006 Individual and small-group interviews Requests for inputs in series Updates Meeting, Bellagio, November 2006 Presentation and discussions today

And in the future

Review and comment on draft papers

The Lancet peer review process

Broad engagement of the global nutrition and health communities, and interaction with the global food community - 3

Coordination with other nutrition-related events and initiatives

The Ending Child Hunger and Undernutrition Initiative

The “Hunger and Health” Report under development by the World Food Programme

Nutrition partners through presentation at meetings and individual discussions

Broad engagement of the global nutrition and health communities, and interaction with the global food community - 4

Publication of related papers in The LancetWhat?

Original researchOf particular interest:

– Large-scale effectiveness evaluations– New evidence linking undernutrition to relevant actions in

sectors other than health– Financial/economic costs of acting at scale to address

undernutrition

When?By 1 May 2007

Where?http://ees.elsevier.com/thelancet/

Paper 1:Maternal and child undernutrition: Global and regional exposures & health consequences

Systematic literature searches

Re-analysis of existing data sets to develop new estimates of:

prevalence and overlap of stunting and wasting among children < 5y

underweight, stunting and wasting as risk factors for cause-specific deaths due to infectious diseases and disability among children < 5y

the prevalence of low birth weight (at term), and its association with neonatal mortality from birth asphyxia and infections

risks associated with deficiencies in vitamin A, zinc, iron, iodine and other micronutrients

risks associated with suboptimal breastfeeding and complementary feeding

global and regional disease burden (deaths and DALYs)

Paper 2:Maternal and child undernutrition:  long-term consequences for adult health?

Systematic literature searches on associations withHuman capital (height, schooling, income, etc)

Risk factors for chronic disease (blood pressure, glucose, overweight, etc)

Chronic diseases (cardiovascular disease, cancer, mental illness, etc)

Re-analysis of data sets from 5 long-running cohort studies in Brazil, Guatemala, India, Philippines and South Africa on associations between MCU, human capital and risk factors for chronic diseases

Paper 3:Global review of nutrition interventions and programs: What works?

Systematic review of global evidence-base on interventions addressing maternal and child undernutrition More in-depth literature searches by 6 review groups in Karachi, Delhi, Dhaka, Pelotas, Davis and London

Outcomes evaluatedGrowth

Micronutrient status & related functional outcomes

Mortality

Morbidity

Birth outcomes

Modeled estimates of stunting and DALYs avertable

Paper 4:What can be done at national level to reduce maternal and child undernutrition?

Selective literature reviews: policy development and implementation; World Bank projects addressing nutrition; large-scale programs (from paper 3 review) Survey of current nutrition policies and program implementation in: (1) 20 countries with stunting prevalence > 20% and 80% of the stunted children; (2) selected countries not included in (1).Re-analysis of existing data

describe types of food eaten by children in the focus countriesexamine coverage levels in 36 high-burden countries for interventions found important in paper 3 review

Focus groups/interviews with policy leaders in developing countries

Paper 5:Effective international action against undernutrition: Why has it proven so difficult and what can be done to accelerate progress?

Systematic reviewsall research output related to nutrition in 6-mo periodlinkages between nutrition outcomes & global change processesmedia coverage

Quantitative analysis of financial flows for nutrition Semi-structured key informant interviews and document review

international organizationsbilateral donors and foundationsuniversities and international research centersprivate sectorNGOs

Problem tree analysis based on program and institutional reviews

Wide dissemination and advocacy based on series findings

Planned launchesLondon (The Lancet)

Washington D.C. (GMMB/Gates)

In high-undernutrition-burden countries (Gates & partners at country level)

Executive summaryFormat accessible to policy makers

Available at time of series publication

Series publication as freestanding booklet

Revised TimelineRevised Timeline

March

May

July

Sep

Nov

2007Results from papers 1 & 3

Full drafts for internal review

Lancet peer reviews

Papers revised & resubmitted

Publication

Papers submitted

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Key issues relating to country programs:Who are the key actors (now and potential) at country level?

What is the role of nutrition policies and plans?

What are practical steps for governments, partners and the private sector to strengthen undernutrition actions at country level?

What country-level needs should be met by the international nutrition community?

Key issues relating to the international system:How can the UN system be made more effective at country level?

How can the SCN increase its focus on results?

What kind of partnership could best bring different groups together?

How to move towards a more streamlined organizational set-up?

How to increase the focus on capacity building?