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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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    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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    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

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    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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    StudyGroup.Maternalandchildundernutrition:globalandregionalexposures and health consequences.Lancet2008;371: 24360.

    2 BhuttaZA,AhmedT,BlackRE,etal,fortheMaternalandChildUndernutrition Study Group. What works? Interventions or maternal andchild undernutrition and survival. Lancet2008;371: 41740.

    3 VictoraCG,AdairL,FallC,etal.Maternalandchildundernutrition:consequences or adult health and human capital.Lancet2008;371: 340-57.

    4 Bryce J, Coitinho D, Darnton-Hill I, et al, or the Maternal and ChildUndernutritionStudyGroup.Maternalandchildundernutrition:eectiveaction at national level. Lancet2008;371: 51026.

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    6 BlackRE,VictoraCG,WalkerSP,andtheMaternalandChildNutritionStudyGroup. Maternal and child undernutrition and overweight in low-incomeand middle-income countries. Lancet2013;publishedonlineJune6.http://dx.doi.org/10.1016/S0140-6736(13)60937-X.

    7 Bhutta ZA, Das JK, Rizvi A, et al, The Lancet Nutrition Interventions ReviewGroup,andtheMaternalandChildNutritionStudyGroup.Evidence-basedinterventionsforimprovementofmaternalandchildnutrition:whatcanbedone and at what cost? Lancet2013;publishedonlineJune6.http://dx.doi.org/10.1016/S0140-6736(13)60996-4.

    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

    8 Ruel MT, Alderman H, and the Maternal and Child Nutrition Study Group.

    Nutrition-sensitiveinterventionsandprogrammes:howcantheyhelptoaccelerate progress in improving maternal and child nutrition. Lancet2013;publishedonlineJune6.http://dx.doi.org/10.1016/S0140-6736(13)60843-0.

    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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    building momentum or impact. Lancet2013;publishedonlineJune6. http://

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    6736(13)61054-5.

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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.

    20 Horton S, Steckel R. Global economic losses attributable to malnutrition19902000andprojectionsto2050.In:LomborgB,ed.Howmuchhaveglobalproblemscosttheworld?Cambridge:CambridgeUniversityPress,2013.

    21 WHO. Proposed global targets or maternal, inant and young child nutrition.WHODiscussionPaper.Geneva:WorldHealthOrganization,2012.

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


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