The Lancet Series on Maternal and Child Nutrition
Launch Symposium
6 June, 2013
Imperial College – St Mary’s Campus
Rothschild Lecture Hall, School of Medicine
Norfolk Place, London
Maternal and Child Undernutrition and Overweight
in Low-and Middle-Income Countries:
Prevalences and Consequences
Robert E Black1, Cesar G Victora2, Susan P Walker3, Zulfiqar A Bhutta4, Parul Christian1,
Mercedes de Onis5, Majid Ezzati6, Sally Grantham-McGregor3,7, Joanne Katz1, Reynaldo
Martorell8, Ricardo Uauy9 and the Maternal and Child Nutrition Study Group
1 Johns Hopkins University
2 Universidad de Federal de Pelotas
3 The University of the West Indies
4 The Aga Khan University and Medical Center
5 World Health Organization
6 Imperial College of London
7 University College London
8 Emory University
9 London School of Hygiene and Tropical Medicine
Series Background
 2008 Series identified need to focus on critical
period during pregnancy and first two years of life,
the 1,000 days in which good nutrition and healthy
growth have lifelong benefits
 2008 Series also called for greater priority for
national nutrition programmes, stronger
integration with health programmes, enhanced
inter-sectoral approaches and more focus and
coordination in the global nutrition system
 Five years on, we re-evaluate problems of maternal
and child undernutrition, consider growing
problem of overweight and obesity for women and
children and assess the current and needed
national and global response
2008 Series Executive Summary
3
Series Overview
 Paper 1: prevalence and consequences of nutritional
conditions during life course from adolescence (for girls)
through pregnancy to childhood and implications for
adult health
Insert Series cover/exec summary
 Paper 2: evidence supporting nutrition-specific
interventions, health impact and cost of scaling up
 Paper 3: nutrition-sensitive interventions and
approaches and their potential to improve nutrition
 Paper 4: the features of an enabling environment for
nutrition and how they can be favourably influenced
 Comment: examines what is currently being done, and
what should be done nationally and internationally
2013 Series Executive Summary
4
Framework for Actions to Achieve Optimum
Fetal and Child Nutrition and Development
5
Adolescent Nutrition
Prevalence (%)
Adolescent Nutrition: Important for Girls,
and for the Future Generation
55
50
45
40
Girls 15-19 who are stunted
35
Girls 15-19 with a low BMI
30
As many as half of all adolescent girls in some countries
25
Girls 15-19 withare
a high BMI
20stunted, increasing risk of complications in pregnancy and
15
delivery and of poor fetal growth
10
5
0
7
Maternal Nutrition
Trends in Thinness and Obesity for Women Aged 20-29 Years in
UN Regions and Globally (1980-2008)
Prevalence of low BMI in adult women has decreased in Africa/Asia since
1980, but remains higher than 10%
Maternal overweight and obesity has increased steadily since 1980;
resulting in increased maternal morbidity and infant mortality
9
Prevalence of Vitamin A and Iodine Deficiencies,
Inadequate Zinc Intake, and Iron Deficiency Anaemia
10
Iron and Calcium Deficiencies Contribute to
Maternal Deaths
Series confirms anaemia is a risk factor for maternal deaths, most
likely due to haemorrhage, the leading cause of maternal deaths
(23% of total deaths)
Calcium deficiency increases the risk of pre-eclampsia, currently the
second leading cause of maternal death (19% of total deaths)
Addressing these deficiencies could result in
substantial reduction of maternal deaths
11
Evidence Highlights Importance of Nutritional
Status in Women Before and During Pregnancy
Short maternal stature may lead to obstructed labour and
maternal and fetal or neonatal death
Maternal stunting and low Body Mass Index increases the risk of
fetal growth restriction (small for gestational age)
Maternal obesity leads to gestational diabetes, pre-eclampsia,
haemorrhage and higher risk of neonatal and infant death
12
Prevalence of SGA Births
32.4 million babies
were born SGA in
2011; 27% of all
births in LMICs
13
Risks of SGA for Mortality and Preterm Birth for
Neonatal Mortality
Reductions in child mortality could be achieved by
targeting interventions to reach babies born too
small or too soon
14
Risk of SGA for Stunting
20% of stunting by
24 months can be
attributed to being SGA
15
Child Nutrition
Stunting Rate is Slowly Decreasing
• Figure 4
165 million
children under
five are stunted
(25.7%)
2.1% annual rate
of reduction is
not fast enough
to reach WHA
target
17
Prevalence of Wasting and Severe Wasting in
Children <5 Years Old by UN Regions, 2011
12
Proportion (%)
10
52 million children under 5 are wasted,
19 million severely wasted
8
Wasting
6
Severe wasting
4
2
0
18
Child Obesity on the Rise
19
Micronutrient Deficiencies
Deficiencies of essential vitamins and minerals continue to be
widespread and have significant adverse effects on child survival
and development, as well as maternal health
Deficiencies of vitamin A and zinc adversely affect child health
and survival, and deficiencies of iodine and iron, together with
stunting, contribute to children not reaching their
developmental potential
Significant progress has been made in addressing vitamin A
deficiency but efforts must continue at current coverage levels to
avoid backsliding because dietary intake of vitamin A is still
inadequate
20
When Coupled with Infectious Diseases,
Wasting Increases Hazard of Death
NEED
TO INSERT
Weight-forAll Deaths
Pneumonia
Deaths
HR
(95% CI)
Diarrhoea
Deaths
HR
(95% CI)
Measles
Deaths
HR
(95% CI)
Other
Infectious
Deaths
HR
(95% CI)
Length
Z-Score
HR
(95% CI)
< -3
11.6
(9.8, 13.8)
9.7
(6.1, 15.4)
12.3
(9.2, 16.6)
9.6
(5.1, 18.0)
11.2
(5.9, 21.3)
-3 to < -2
3.4
(2.9, 4.0)
4.7
(3.1, 7.1)
3.4
(2.5, 4.6)
2.6
(1.3, 5.1)
2.7
(1.4, 5.5)
-2 to < -1
1.6
(1.4, 1.9)
1.9
(1.3, 2.8)
1.6
(1.2, 2.1)
1.0
(0.6, 1.9)
1.7
(1.0, 2.8)
≥ -1
1.0
1.0
1.0
1.0
1.0
21
When Coupled with Infectious Diseases,
Stunting Increases Hazard of Death
Height/Length
All Deaths
NEED
TO INSERT
Pneumonia
Deaths
HR
(95% CI)
Diarrhoea
Deaths
HR
(95% CI)
Measles
Deaths
HR
(95% CI)
Other
Infectious
Deaths
HR
(95% CI)
-for-Age
Z-Score
HR
(95% CI)
< -3
5.5
(4.6, 6.5)
6.4
(4.2, 9.8)
6.3
(4.6, 8.7)
6.0
(3.0, 12.0)
3.0
(1.6, 5.8)
-3 to < -2
2.3
(1.9, 2.7)
2·2
(1.4, 3.4)
2.4
(1.7, 3.3)
2.8
(1.4, 5.6)
1.9
(1.0, 3.6)
-2 to < -1
1.5
(1.2, 1.7)
1.6
(1.0, 2.4)
1.7
(1.2, 2.3)
1.3
(0.6, 2.6)
0.9
(0.5, 1.9)
> -1
1.0
1.0
1.0
1.0
1.0
22
Prevalence of Stunting and Overweight for Highest
and Lowest Wealth Quintiles in Selected Countries
23
Breastfeeding Practices by UN Region During
2000-2010
90
80
Exclusive breastfeeding only about 30% or less
in major UN regions
Early initiation of breastfeeding
(Percentage)
70
Exclusive breastfeeding (1-5 months)
60
50
Predominant breastfeeding (1-5 months)
40
Partial breastfeeding (1-5 months)
30
No breastfeeding (1-5 months)
20
Any breastfeeding (6-23 months)
10
0
Africa
Latin America
Asia
Europe
24
Child Mortality Due to Nutritional Disorders
Attributable
deaths with UN
prevalences*
Proportion of total
deaths of children
younger than 5
years
817,000
11.8%
1,017,000*
14.7%
Underweight (1-59 months)
999,000*
14.4%
Wasting (1-59 months)
Severe Wasting (1-59 months)
875,000*
516,000*
12.6%
7.4%
Zinc deficiency (12-59 months)
116,000
1.7%
Vitamin A deficiency (6-59 months)
157,000
2.3%
Suboptimum breastfeeding (0-23 months)
804,000
11.6%
Joint effects of fetal growth restriction and suboptimum
breastfeeding in neonates
1,348,000
19.4%
Joint effects of fetal growth restriction, suboptimum breastfeeding,
stunting, wasting, and vitamin A and zinc deficiencies (<5 years)
3,097,000
44.7%
Nutritional Disorders
Fetal growth restriction (<1 month)
Stunting (1-59 months)
Data are to the nearest thousand. *Prevalence estimates from the UN.
25
Child Deaths Attributed to Nutritional
Conditions
Undernutrition (fetal growth restriction, sub-optimal
breastfeeding, stunting, wasting and deficiencies of vitamin A
and zinc) is responsible for 45% of all under five child deaths,
representing more than 3 million deaths each year (3.1 million of
the 6.9 million child deaths in 2011)
Fetal growth restriction and sub-optimal breastfeeding together
are responsible for more than 1.3 million deaths, or 19.4% of all
under five child deaths, representing 43.5% of all nutritionrelated deaths
Deficiencies of vitamin A and zinc are responsible for nearly
300,000 child deaths
26
Paper 1 Key Messages
Short stature, low BMI and vitamin and mineral deficiencies in pregnancy
contribute to maternal morbidity and mortality, fetal growth restriction,
infant mortality and stunted growth and development
Stunting of growth in the first 2 years of life affects 165 million children
who have elevated risk of mortality, cognitive deficits and increased risk
of adult obesity and non-communicable diseases
Vitamin A and zinc deficiencies in young children increase the risk of
death from infection and other micronutrients have important
developmental consequences
This new evidence strengthens the case for a continued focus on the
critical 1,000 day window during pregnancy and the first two years of life,
highlighting the importance of intervening early in pregnancy and even
prior to conception
27