34th Session of the Standing Committee on Nutrition:
Working Together
Third Session
Monday, 26 February
Achieving Freedom from Maternal
and Child Undernutrition:
An Update on The Lancet Series
Saul S. Morris
London School of Hygiene & Tropical Medicine (Honorary)
Outline
Series basics
Progress in the three streams of series
activity
Revised timeline
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Series 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 Adair
Tahmeed Ahmad
Lindsay Allen
Zulfiqar Bhutta*
Robert Black**
Martin Bloem
Jennifer Bryce*
Laura Caulfield
Denise Coitinho
Simon Cousens
Ian Darnton-Hill
Mercedes de Onis
Majid Ezzati
Bruce Cogill
Boitshepo Giyose
Pedro Hallal
Betty Kirkwood
Reynaldo Martorell
Saul Morris*
David Pelletier
Per Pinstrup-Anderson
Linda Richter
Juan Rivera
Marie Ruel
Harshpal Sachdev
Meera Shekar
Roger Shrimpton
Ricardo Uauy
Cesar 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.
Conceptual framework
for the series
Short-term consequences:
Long-term consequences:
Mortality, morbidity, disability
Adult size, intellectual ability, economic productivity,
reproductive performance, metabolic and
cardiovascular disease
Maternal & child
undernutrition
Inadequate
dietary intake
Household
food
insecurity
Underlying
causes
Disease
Inadequate
care
Immediate
causes
Unhealthy household
environment & lack of
health services
Income poverty:
employment, self-employment, dwelling, assets, remittances,
pensions, transfers, etc.
Lack of capital:
financial, human, physical, social and natural
Basic
causes
Social, economic and political context
Adapted from UNICEF, 1998
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
three
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 Lancet
What?
Original research
Of 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 with
Human 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 evaluated
Growth
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
countries
examine 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 reviews
all research output related to nutrition in 6-mo period
linkages between nutrition outcomes & global change
processes
media coverage
Quantitative analysis of financial flows for nutrition
Semi-structured key informant interviews and document
review
international organizations
bilateral donors and foundations
universities and international research centers
private sector
NGOs
Problem tree analysis based on program and
institutional reviews
Wide dissemination and advocacy
based on series findings
Planned launches
London (The Lancet)
Washington D.C. (GMMB/Gates)
In high-undernutrition-burden countries (Gates &
partners at country level)
Executive summary
Format accessible to policy makers
Available at time of series publication
Series publication as freestanding booklet
Revised Timeline
2007
March
May
Results from papers 1 & 3
Full drafts for internal review
Papers submitted
July
Lancet peer reviews
Papers revised & resubmitted
Sep
Publication
Nov
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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?